As the dust settles after the Francis report we can expect Trusts around the country to respond. The nature of that response of course will be crucial. Will the focus be on the structures (e.g. poor skill mix, lack of training, minimal staffing, bureaucratic target led mangement) that produced the ground for poor and abusive care, or will clinical staff be subjected to more management ‘initiatives?’ We may also wait for top down government advice and policy direction, but will there be resources to support it?
Roy Lilley on nhsManagers.net alerts us to the latest initiative from the United States, that is coming our way: Don Berwick ‘s Zero Harm. Berwick has been invited to the UK to speak to David Cameron. A good deal of the leadership and management theory comes from the United States and developed within the private sector. Will Berwick’s ideas travel?
Roy points out that we have had many management initiatives before: ‘The Organisation With a Memory’, ‘Quality Circles’, ‘Six Sigma’, ‘Evidence Based Management’, ‘Process Reengineering’, ‘Matrix Management’, ‘TQM’.
Clinical staff working to provide good quality care have seen these processes come and go. These processes develop into a form of organizational culture that require bureaucracy creep, and let’s not forget that it was culture that was heavily criticised by Francis.
The culture of NHS organisations is characterised by increased bureaucracy and the application of rationality to problem solving. One of the founders of sociological theory in the 19th century, Max Weber, suggested rationality involves an individual cost-benefit calculation, wider bureaucratic organisation and the opposite of understanding society reality through mystery and magic, the waning of a religious and spiritual understanding of modernity which he called ‘disenchantment’. This has an upside in that social practices were now subject to analysis and examination rather than based on the authority of Popes and priests.
Weber’s theory of ‘rationalisation’ thus suggests that modern societies become increasingly rational and bureaucratic whereby social life becomes more and more prone to scientific analysis, measurement, bureaucratic control and the application of ‘instrumental rationality’ to social problems and issues. Instrumental rationality is a mode of thought and action that identifies problems and works directly towards their solution, often focusing on the most efficient and cost effective methods of achieving certain ends. It may not stop to ask what those ends should be, or what effect the efficiency has on human relationships or the cultures of organisations. A falls risk assessment could be seen as an efficient and cost effective measure to reduce the number of falls and it is part of the overall instrumental rational approach to risk management in an acute hospital. Actually constraining a patient’s mobility to prevent a fall may be rational but it may not be human.
What clinical staff require is a proper structure to work in, not more bureaucratic processes that spuriously attempt to deliver and measure ‘quality’ or the eradication of risk entirely as part of an unattainable ‘zero harm’ process.
According to Roy Lilley these ‘fads’ all fail because they don’t always have ownership and backing by top management; in addition pressurised managers end up leading organisations to take short-cuts in deployment, bits of the latest fad are cherry picked and I would say importantly clinical outcomes are never measured. So how do we really know they work?
Berwick’s ‘Zero Harm’ is an approach used in industry to stop accidents. Roy is not impressed, he argues that “There are hundreds of consultancies flogging it. Here’s an example of some of their snake oil:
“…sustaining a work environment which supports the health and safety of our people and minimises the impact our business has on the environment… building strong relationships with the community, governments, shareholders, contractors, our supply chain and growing our business in a sustainable way.….”.
Fine words indeed but what is the effect?
The goal may be unattainable, and getting there will require data collection, comparisons, benchmarking, recording, measuring, goals, targets, bureaucracy, labels, tables, blame…..just the sort of processes that form a particular management culture obsessed by target reduction and corporate objectives rather than clinical care.
This is the context in which cultures develop. In this post called ‘undignified care’ I refer to a paper by Hillman et al (2013) who argue that in an analysis of poor care:
“Cultural and institutional contexts of healthcare delivery are often missing…the maintenance of dignified care has…been focused upon individual attitudes and behaviours…(while) maintaining dignity depend(s) on more than the commitment of individuals” (p4).
It is as if we consider that individual nurses’ attitudes and behaviours are the most important aspect of the care experience, forgetting that the organisational context in which they work may seriously degrade their ability to do so. The need for a contextual analysis is supported by Hewison and Griffiths (2004) who argued:
“Too much emphasis on leadership without an equal concern for transforming the organisations nurses…work in, may result in leadership being added to the list of transient management ‘fads’ which have characterised health care in recent years” (p 464).
Roy Lilley’s concern seems to be that Berwick’s ‘zero harm’ approach will be just another fad, that will not deliver. He argues:
“The concept of Zero comes from the language of the past. As important as the ethos of ‘Zero’ might be, as a management philosophy it is past its sell-by date. Zero lives in the world of strategy and bureaucracy when we need tactics and techniques. Nimble organisations, empowered to deal with what needs to be done where they are, not Whitehall. A focus on training, front-line and dumping the rest”.
Watch out for ‘zero harm’ coming to place near you…..it will sound plausible but will it work? Listen to your patients, exercise your duty of candour, network with like minded clinicians and wrest leadership back to the front line.
Roy Lilley: ‘A better start’ nhsmangers.net 13th February 2013