Hospital

Transformation
From Failure to Success
and Beyond
Derek Burke
Prasad Godbole
Andrew Cash
Editors

123
Hospital Transformation
Derek Burke • Prasad Godbole
Andrew Cash
Editors

Hospital Transformation
From Failure to Success and Beyond
Editors
Derek Burke Prasad Godbole
Sheffield Children’s NHS Foundation Sheffield Children’s NHS Foundation
Trust Trust
Department of Emergency Medicine Department of Paediatric Surgery
Sheffield Sheffield
UK UK

Andrew Cash
Sheffield Teaching Hospitals NHS
Foundation Trust
Sheffield
UK

ISBN 978-3-030-15447-9    ISBN 978-3-030-15448-6 (eBook)

https://doi.org/10.1007/978-3-030-15448-6

© Springer Nature Switzerland AG 2019

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Foreword

This book is about balancing the sometimes-competing pressures of provid-

ing safe, high-quality hospital care within whatever resources a community is
prepared to provide or the patient [or their insurer] is willing to pay. Throw
into the mix the need for a learning culture, staff satisfaction, harmonious and
effective team working, a good patient experience and high public esteem and
the authors are searching for the illusive gold standard of hospital care and
how to achieve it. Their search is internationally based and draws on research
and evaluative studies from many countries.
Although the focus of the work is transforming hospitals, it gets deep into
the wider policy and structural issues that frame the context in which hospi-
tals have to perform. The contrast between a modern hospital in a developed
society and one in a war-torn country is striking. Both are striving to achieve
the best that is possible with the resources available to them.
The early chapters describe in some detail the various regulatory frame-
works into which hospitals have to sit. Regulators play an increasingly impor-
tant role, alongside health professional bodies, in setting standards which the
successful hospital must attain. Some standards such as those relating to
building and environmental safety are relatively clear but others such as
adopting only evidence-based medicine across the whole organisation are
more challenging, more fluid and sometimes more controversial. The best
regulators and systems of accreditation are moving from inspection and com-
pliance to systems of continuous improvement.
Different models of funding health systems are described and their
strengths and weaknesses examined. Providing affordable health care to the
poor and minority groups is a common challenge. Those countries such as
Chile which have moved from one system to another provide a fascinating
insight into the politics of health policy.
Although focused on success, the authors also examine why hospitals fail
or find their standards dropping. How a hospital reacts to a change in eco-
nomic circumstances without compromising its quality standards is an ever-
present challenge for hospital managers and the leaders of health professions.
In every country the gap between what medicine can achieve and what can be
afforded appears to be growing. Hospitals and their specialist staff are usually
at the leading edge of this challenge. Measuring clinical quality can be par-
ticularly demanding and the authors discuss means of identifying and dealing
with unacceptable variations in clinical outcome.
Leadership is vital to sustained transformation. The most successful lead-
ers build organisations that reflect a high degree of professional consensus
v
vi Foreword

about their aims and objectives. Their standards are often set higher than
those specified by their external regulators. Strong leadership is diffused
throughout the organisation, but the individuals concerned share the same
attitudes and objectives. Medical leadership and particularly the role of the
Medical Director is examined in some detail as is the concept of clinical gov-
ernance. The best hospital organisations commonly have a high commitment
to professional and nonprofessional training. This commitment usually means
that the organisation is more open to regular internal challenge and new ideas.
Case studies drawn from both local and country-wide settings illuminate the
text. An Australian case study examines the role of hospital boards. The UK
study highlights the need for long-term but flexible plans to shape the future and
provide the skilled human resources upon which success will be dependant.
Hospitals do not exist in a static world. In developed societies they have to
adjust to increasingly elderly populations, constant and sometimes startling
scientific change as well as economic and political pressures. The emergence
of gene therapies and tailor-made medicines are but two examples. Every
new scientific development usually leads to increased cost and new demand.
Patient expectation almost always keeps pace with new science. Health pro-
fessions will always want to deploy their new skills and patients want to ben-
efit. It’s almost a perfect storm!
Integrated health care is now widely accepted as the hallmark of excellent
clinical practice. This means that the hospital and its staff have to find ways
to blend their skills with others who are providing care and support including
those in primary care and public health. This has to be done both at a com-
munity level and at the level of each patient. The authors drive home the point
that biomedicine does not provide all the answers. Social care, family cohe-
sion, housing, employment and poverty all impact on the health of communi-
ties. Hospitals need to play their part in the development of systems of health
care as well as being centres for the treatment of illness.
The authors consider how successful hospitals begin the process of con-
stant transformation. They distinguish between changes that produce short-
term gain and those that imbed long-lasting quality changes into the core of
the hospital. ‘This is how we do it here is a powerful motto’. Successful
hospitals almost always have patients at the core of both professional practice
and managerial culture.
This book illustrates clearly how complex modern hospital organisations
have become. But it also provides grounds to be confident that with the right
leadership they can cope well with the tensions and challenges they face. It’s
not easy but it can be done.
Each chapter is well referenced for readers who want to explore beyond
the words and ideas set out by the authors.
This work deserves a place on the book shelf of everybody involved in the
hospital world. It’s a ‘keep going back to’ book as health professionals, manag-
ers, politicians and patients continue the search for that illusive gold standard.

Brian Edwards
Former President of European Hospital Federation
Emeritus Professor of Health Care Development
University of Sheffield
Sheffield, UK
Preface

Delivering high-quality healthcare services is predicated on achieving a bal-

ance between the cost of providing the service, the income derived from
delivering that service (productivity and performance) and maintaining qual-
ity and safety.
A ‘successful’ hospital is one which can achieve the care standards stipu-
lated by their regulators and at the same time deliver a financially robust ser-
vice with excellent outcomes and patient experience.
The increasing burden of chronic illness combined with increased life
expectancy due to advances in medicine and innovative technologies is put-
ting a financial strain on many healthcare organisations. Patient awareness
and expectations of better outcomes and experience is rising at the same time
as the political imperative is to constrain costs. This conflict can tend to sway
the balance towards services that become more focussed on balancing the
books rather than on patient safety and quality. It is in such circumstances that
hospitals may find themselves in a downward spiral of increasing costs and/
or deterioration in the level of safety and performance with management con-
flicted as to how to turn this situation around.
This book addresses these issues with a global perspective. Individual
chapters along with case studies where applicable give an insight into the
challenge that healthcare organisations face on a global scale. The transfor-
mation and turnaround process and sustainability following transformation
with practical examples are also addressed. All chapters can be read as stand-
alone or sequentially.
The book is aimed at all healthcare staff, particularly those in leadership
positions and in managerial roles whether clinical or non-clinical.
We would like to take the opportunity to thank our esteemed team of con-
tributors for their timely submission of their contributions without which this
book would have been impossible. We are grateful for the support and guid-
ance of Melissa Morton, Executive Editor at Springer Science and Business
Media, and Prakash Marudhu Project Coordinator for Springer Nature.
Finally, we would like to thank our families who have supported and
encouraged us through this venture without which this would not have been
possible.

Sheffield, UK Derek Burke

Sheffield, UK  Prasad Godbole
Sheffield, UK  Andrew Cash

vii
Contents

Part I Requirements of Basic Healthcare Globally

1 Regulatory Requirements for Healthcare Globally����������������������   3

Prasad Godbole
2 Opportunities and Challenges in Global Healthcare��������������������   7
Tim Tomlinson and Prasad Godbole

Part II Models of Healthcare Provision

3 Models of Healthcare in Developed and

Developing Countries���������������������������������������������������������������������� 15
Prasad Godbole and Matthew Kurian

Part III Provision of Effective, Safe and Good Quality Care

4 How Do Hospitals Deliver Safe, Effective and

High Quality Care?�������������������������������������������������������������������������� 23
Patrick Dobbs

Part IV Identifying Failure

5 Transforming Hospital Accreditation:

From Assurance to Improvement �������������������������������������������������� 35
Stephen Duckett and Christine Jorm
6 Key Features in Identifying Failing Hospitals������������������������������ 43
Rivanna Stuhler and Martin A. Koyle
7 The Illness of the Health Care Systems������������������������������������������ 51
Jaime Llambías-Wolff
8 The Political Economy of Health Reforms in Chile:
A Case Study of the Privatization Process������������������������������������ 59
Jaime Llambías-Wolff

ix
x Contents

Part V The Turnaround Process

9 The Role of Medical Leadership in the

Hospital Turnaround Process���������������������������������������������������������� 73
Prasad Godbole and Derek Burke
10 Public Health Service Governance:
Principles and Framework�������������������������������������������������������������� 81
Erwin Loh and Katherine Lorenz
11 Hospital Transformation: How Is it Done?������������������������������������ 95
Prasad Godbole and Derek Burke

Part VI Sustainability

12 Sustainable Hospital Transformation and Beyond ���������������������� 107

Stephen Stericker and Dawn Lawson

Part VII Overcoming the Challenge

13 The National Health Service in the UK������������������������������������������ 125

Andrew Cash

Index���������������������������������������������������������������������������������������������������������� 131
Contributors

Derek Burke Department of Emergency Medicine, Sheffield Children’s

NHS Foundation Trust, Sheffield, UK
Andrew Cash Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK
Patrick Dobbs Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK
Stephen Duckett Grattan Institute, Carlton, VIC, Australia
Prasad Godbole Department of Paediatric Surgery, Sheffield Children’s
NHS Foundation Trust, Sheffield, UK
Christine Jorm NSW Regional Health Partners, Newcastle, NSW, Australia
Martin A. Koyle The Hospital for Sick Children (SickKids), Toronto, ON,
Canada
Department of Surgery, University of Toronto School of Medicine, Toronto,
ON, Canada
Matthew Kurian Doncaster and Bassetlaw NHS Foundation Trust,
Doncaster, UK
Dawn Lawson Liverpool Health Partners, Liverpool, UK
Jaime Llambías-Wolff York University, Toronto, ON, Canada
Erwin Loh Monash Centre for Health Research and Implementation,
Monash University, Clayton, VIC, Australia
Katherine Lorenz Monash Centre for Health Research and Implementation,
Monash University, Clayton, VIC, Australia
Stephen Stericker Care to Innovate, NHS and Social Care, York, UK
Rivanna Stuhler The Hospital for Sick Children (SickKids), Toronto, ON,
Canada
The Institute for Health Policy, Management, and Evaluation (IHPME),
University of Toronto, Toronto, ON, Canada
Tim Tomlinson Pioneer Healthcare Limited, Sheffield, UK

xi
 Part I
Requirements of Basic Healthcare Globally
 Regulatory Requirements
for Healthcare Globally 1
Prasad Godbole

Introduction E. To ensure quality assurance and patient

focused healthcare delivery as well as finan-
Every individual has a right to basic healthcare. cial integrity
With increasing patient awareness and expecta-
tion, it goes without saying that hospitals have Where any of these regulatory processes are
to deliver healthcare that is patient focused, not complied with, inevitably patient safety will
meets the demands of the patients, is provided be compromised.
in collaboration with patient views and is cost
effective. Anyone going into hospital does so
with the inherent notion of receiving safe treat- I s Regulation of Healthcare Services
ment. However how can patient safety be guar- Truly Global?
anteed? It is here that hospitals have to adhere to
regulatory requirements. Regulations are there In both the developed and developing countries,
irrespective of the model of healthcare delivery: there is regulation of healthcare service provi-
sion. While this regulation exists, the imple-
A. To ensure that the hospitals themselves pro- mentation and adherence to regulation may vary
vide a safe environment in which to work and depending on the geopolitical climate. For exam-
provide treatment—structural regulations, ple in war torn countries, regulation although
licensing and accreditation present cannot necessarily be monitored when
B. The systems and processes in hospitals are the prime task of the workforce is to save lives
such that patients will receive safe treat- in the most inhospitable conditions. Furthermore
ment—licensing and accreditation in certain developing countries where it is diffi-
C. To ensure that Doctors and nurses treating the cult to access any sort of healthcare, alternative
patients have the appropriate qualifications and medical practitioners may practice traditional
experience—medical regulatory authorities allopathic medicine with scant regard to the
D. To ensure that the best evidence is used when regulations. Even in developed countries such as
treating patients—compliance with National the U.K. male non therapeutic circumcisions are
Guidelines or international guidelines undertaken in the community by general prac-
titioners and religious leaders with very little
audit or control of outcomes or facilities where
P. Godbole (*) they are undertaken (https://www.bma.org.uk/
Department of Paediatric Surgery, Sheffield advice/employment/ethics/children-and-young-
Children’s NHS Foundation Trust, Sheffield, UK
e-mail: Prasad.Godbole@sch.nhs.uk people/male-circumcision). In Africa although

© Springer Nature Switzerland AG 2019 3

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_1
4 P. Godbole

female genital mutilation is illegal, this is still II, increased world trade in manufactured goods
practiced on cultural grounds (http://www.who. led to the creation of the International Standards
int/news-room/fact-sheets/detail/female-genital- Organization (ISO) in 1947 [2]. Accreditation
mutilation). This highlights the fact that while formally started in the United States with the for-
regulations for hospitals may be global, the mation of the Joint Commission on Accreditation
implementation and monitoring to achieve global of Healthcare Organizations (JCAHO) in 1951.
patient safety is far from ideal. This model was exported to Canada and Australia
in the 1960s and 1970s and reached Europe in the
1980s. Accreditation programs spread all over
Structural Regulations the world in the 1990s [3]. There are other forms
of systems used worldwide to regulate, improve
For any new healthcare facility, each country and market the services of healthcare providers
has a specific building code for civil works. and organizations, including Certification and
For hospital design, functional space planning Licensure. Certification involves formal recogni-
guidelines are available which outline interde- tion of compliance with set standards (e.g., ISO
pendencies, co adjacencies and functional flow. 9000 standards) validated by external evaluation
Regulations for fire safety, HVAC (heating, ven- by an authorized auditor. Licensure involves a
tilation and air conditioning), electromechanical process by which governmental authority grants
configurations exist. These regulatory codes are permission, usually following inspection against
most commonly used for new hospital builds minimal standards, to an individual practitio-
and can be used for the commissioning process ner or healthcare organization to operate in an
of new builds. These codes also include room occupation or profession [3]. Although the terms
data sets with finishing and fittings. Examples accreditation and certification are often used inter-
of this are the Health Building Notes (HBN) changeably, accreditation usually applies only to
(https://assets.publishing.service.gov.uk/gov- organizations, while certification may apply to
ernment/uploads/system/uploads/attachment_ individuals, as well as to organizations [2]. In
data/file/316247/HBN_00-01-2.pdf), ASHE summary, licensing is a mandatory regulatory
guidelines (http://www.ashe.org), International requirement for hospitals and individuals to prac-
Health Planning Guidance (https://www. tise. Accreditation has been shown to improve
wbdg.org/building-types/health-care-facilities/ the quality of healthcare outcomes [4] and is vol-
hospital) and local civil and building regula- untary e.g. Joint Committee International (JCI)
tions for hospitals such as the Indian Code for (https://www.jointcommissioninternational.org)
Hospital Builds (https://archive.org/details/gov. accreditation of hospitals or departments.
in.is.12433.1.1988/page/n5).

Medical Regulatory Authorities

Licensing and Accreditation
For any doctor or nurse to practice, they have
Accreditation is usually a voluntary program, to have gained the appropriate qualification and
sponsored by a non-governmental organization experience and been registered with their coun-
(NGO), in which trained external peer reviewers try’s medical or nursing medical authority. This
evaluate a healthcare organization’s compliance registration may or may not be transferable from
and compare it with pre-established performance one country to the other. For example the basic
standards [1]. Quality standards for hospitals medical qualification from India is not recog-
and other medical facilities were first introduced nised in the European Countries or the US and
in the United States in the “Minimum Standard doctors have to complete that country’s qualify-
for Hospitals” developed by the American ing exams to enable them to get further train-
College of Surgeons in 1917. After World War ing and license/certificate to practice once the
1 Regulatory Requirements for Healthcare Globally 5

performance standards are achieved. In certain outcomes by individual hospital and clinician.
countries like the U.K. doctors have to undergo Key reporting requirements include incidence
a process of revalidation every 5 years (https:// of MRSA, C. Difficile, hospital acquired urinary
www.england.nhs.uk/medical-revalidation/ tract infections, deep vein thrombosis, pressure
doctors/10-steps/) to ensure that they remain up ulcers etc.
to date with no concerns to the public about their Furthermore every hospital in the U.K. that
competence or performance. Similarly doctors have been given Foundation Trust status (status
and nurses from non English speaking countries to operate independent of government control)
(excluding EU countries) have to pass an English is licensed by Monitor (https://www.gov.uk/gov-
proficiency test prior to working in the U.K. ernment/organisations/monitor) and regulated
(https://www.ielts.org). by the Care Quality Commission (https://www.
cqc.org.uk). The focus of the CQC is primarily
patient safety, patient focus and experience and
 vidence Based Medicine
E quality and effectiveness. Hospitals are rated
and Regulation from outstanding to inadequate and where appro-
priate hospitals may be put into special measures
It is estimated that upto 48 million Americans to enable a hospital turnaround process to be
suffer from chronic pain daily leading to an esti- undertaken. These regulatory mechanisms also
mated cost per annum of between $560 and 635 oversee financial integrity of the institutions who
million [5] and loss of productivity [6]. It was are given a financial risk rating [9].
long thought that opioids prescribed for chronic
pain did not cause addiction, however this has
now shown to be untrue [7]. The CDC issued Conclusion
guidance on prescribing opioids for chronic pain
[8]. Similarity the National Institute for Health There are certain key regulatory requirements for
and Care Excellence (NICE) (https://www.nice. any healthcare provider globally. These include
org.uk) publishes evidence based guidance for regulatory frameworks from hospital build to
which there is a mandatory reporting requirement patient care and regulations for all individuals
for hospitals to demonstrate compliance. providing the care. However these regulatory
frameworks are not consistent or standardised
and it is therefore imperative that there is collabo-
Quality Assurance and Regulation ration on a global scale to ensure patient safety.

The regulatory requirements regarding quality

assurance vary from country to country. While References
many countries have a mandatory requirement
to publish outcomes for key conditions such as 1. Shaw CD. Toolkit for accreditation programs. The
International Society for Quality in Health Care,
cancer treatment, joint replacements etc., many Australia; 2004.
countries do not publish such data. Furthermore 2. Montagu D. Accreditation and other external quality
in countries where many clinicians are private assessment systems for healthcare: review of experi-
practitioners, there may not be auditable data of ence and lessons learned. London: Department for
International Development Health Systems Resource
their practice despite regulations being in place. Centre. Available from: http://www.dfidhealthrc.org/
In certain regions of the world, quality assurance publications/health_service_delivery/Accreditation.
is non existent. From personal experience, this pdf. Accessed 2003.
situation is prevalent in war torn countries. 3. Shaw CD. External quality mechanisms for health
care: summary of the ExPeRT project on visita-
In the U.K. every NHS Trust is mandated to tie, accreditation, EFQM and ISO assessment in
provide a safety thermometer (https://www.safe- European Union countries. External peer review tech-
tythermometer.nhs.uk) or dashboard as well as niques. European foundation for quality management.
6 P. Godbole

International organization for standardization. Int J 7. Banta-Green CJ, Merrill JO, Doyle SR, Boudreau
Qual Health Care. 2000;12:169–75. DM, Calsyn DA. Opioid use behaviors, mental health
4. Alkhenizan A, Shaw C. Impact of accreditation on the and pain-development of a typology of chronic pain
quality of healthcare services: a systematic review of patients. Drug Alcohol Depend. 2009;104:34–42.
the literature. Ann Saudi Med. 2011;31(4):407–16. 8. Dowell D, Haegerich T, Chou R, et al. CDC guideline
5. Nahin Richard L. Estimates of pain prevalence for prescribing opioids for chronic pain. United States,
and severity in adults: United States, 2012. J Pain. 2016. MMWR Recomm Rep. 2016;65(1):1–49.
2015;16(8):769–80. 9. The regulation and oversight of NHS trusts and NHS
6. Institute of Medicine (US) Committee on Advancing foundation trusts. Joint policy statement to accom-
Pain Research, Care, and Education. Relieving pain pany care bill quality of services clauses. Available
in America: a blueprint for transforming preven- at https://assets.publishing.service.gov.uk/govern-
tion, care, education, and research. Washington, DC: ment/uploads/system/uploads/attachment_data/
National Academies Press; 2011. file/200446/regulation-oversight-NHS-trusts.pdf.
 Opportunities and Challenges
in Global Healthcare 2
Tim Tomlinson and Prasad Godbole

Introduction All individuals equate high quality healthcare

with a good quality of life. This is at the forefront
The world continues to become a smaller place of most governments thinking and ranks highest
made possible by growing access to Internet, alongside the economy as a political issue. In the
online services and less expensive air travel. An U.K., the National Health Service has faced sig-
increasing number of developing countries are nificant challenges in continuing to provide
experiencing economic growth far in excess of healthcare free at the point of delivery.
previous years with real growth in GDP at rate This chapter will discuss the challenges facing
well above the levels in the recognised developed global healthcare and the opportunities that have
world of USA and Europe [1]. The period of aus- arisen as a result with the aim of providing a con-
terity continues its grip and the gap between the sistent, high quality healthcare to basic minimum
Middle East previously seen as cash rich is nar- standards. The chapter is based on literature but
rowing as the reliance on oil as the main source also personal experience of the authors in the
of energy reduces. There are now wide opportu- delivery of international healthcare.
nities across the globe to partner with govern-
ments and private providers aspiring to develop
healthcare to levels of international standards. Global Healthcare Challenges
However, the challenges of global healthcare
remain significant. Dr. Margaret Chan, Director Population Demographics
General of the WHO states: and Disease Pattern
We want to see better health and well-being for all,
as an equal human right. Money does not buy bet- It is well known that people are living longer
ter health. Good policies that promote equity have thanks to emerging new technologies and
a better chance. We must tackle the root causes (of advances in science. The average life expectancy
ill health and inequities) through a social determi-
nants approach that engages the whole of govern- of the population in the OECD countries is
ment and the whole of society. approximately 80 years (https://www.oecd.org/
berlin/47570143.pdf). However in many cases,
T. Tomlinson this increased life expectancy is linked to chronic
Pioneer Healthcare Limited, Sheffield, UK disease requiring lifelong treatment [2].
e-mail: ttomlinson@pioneerhealthcare.co.uk Globally, the rate of deaths from noncommu-
P. Godbole (*) nicable causes, such as heart disease, stroke, and
Department of Paediatric Surgery, Sheffield injuries, is growing. At the same time, the num-
Children’s NHS Foundation Trust, Sheffield, UK
e-mail: Prasad.Godbole@sch.nhs.uk ber of deaths from infectious diseases, such as

© Springer Nature Switzerland AG 2019 7

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_2
8 T. Tomlinson and P. Godbole

malaria, tuberculosis, and vaccine-preventable breaks due to food borne infections, poor quality
diseases, is decreasing [3]. Many developing pharmaceuticals, and contaminated consumer
countries must now deal with a “dual burden” of goods.
disease [4]: they must continue to prevent and The world community is finding better ways
control infectious diseases, while also addressing to confront major health threats. WHO, through
the health threats from noncommunicable dis- the 2005 IHR External Web Site Policy (http://
eases and environmental health risks. As social www.who.int/ihr/procedures/implementation/
and economic conditions in developing countries en/), proposes new guidance and promotes coop-
change and their health systems and surveillance eration between developed and developing coun-
improve, more focus will be needed to address tries on emerging health issues of global
noncommunicable diseases, mental health, sub- importance. The IHR require countries to develop
stance abuse, eating disorders and especially, appropriate surveillance and response capacities
injuries (both intentional and unintentional). to address these health concerns. All of these
Some countries are beginning to establish pro- issues will require internationally enhanced col-
grams to address these issues. For example, laboration with other countries to protect and
Kenya has implemented programs for road traffic promote better health for all.
safety and violence prevention (http://www.who.
int/violence_injury_prevention/road_traffic/
countrywork/ken/en/). Cost Control
Other countries are facing new issues. In
China for example 400,000 new HIV cases have Promoting health in current times of austerity can
been seen in the last 12 months (WHO) [5]. be a daunting task. With more and more technol-
Transmission of HIV was previously almost ogies emerging and the focus shifting to patient
entirely caused by infected blood products which centred care and patient autonomy, it can be dif-
has been replaced by infection via sexual contact ficult to provide these technologies (sometimes
due in the main to legalisation of single sex rela- experimental) to patients who demand it.
tionships. With an associated cultural stigma of Spending on healthcare outstrips the GDP of
same sex relationships existing in China and not- most countries in the developed world [6]. This
ing that most men actually marry in to a hetero- combined with austerity measures and ‘doing
sexual relationship the disease is affecting the more for less’ is a significant challenge facing
male and female population. most governments. With the complex interrela-
While health promotion and developing tionships between insurers, hospitals and patients
healthy lifestyles is likely to have an impact on in countries where healthcare is not free, this can
chronic disease in the long term, health econo- lead to differences in coverage of the population
mies will still face the burden of management to various interventions. In some of the GCC
and treatment for the affected generation. countries, this has led to marked differences in
Obesity for example is becoming a major prob- what healthcare interventions will be paid for by
lem globally with its attended consequences the insurers and what the patients themselves
including diabetes, cardiovascular and respira- have to pay for.
tory diseases.
A key challenge in many underdeveloped
countries is to introduce primary care services as Human Resources and the Workforce
both provider and gatekeeper backed up by infor-
mation/data to support a cost effective secondary Staff in most of Haiti’s 19 public hospitals have
and tertiary care system. been on strike for a long time (https://www.daily-
Expanding international trade introduces new mail.co.uk/wires/ap/article-4137896/Staff-
health risks. A complex international distribution strikes-shutter-Haitis-public-hospitals.html),
chain has resulted in potential international out- Jamaica is in the midst of a health care crisis as
2 Opportunities and Challenges in Global Healthcare 9

specialised nurses leave the country en masse for lenge which requires joint initiatives probably at
jobs in North America and Europe (http://www. a government to government level. However,
loopjamaica.com/content/nurses-exodus-contin- while training can be provided to a certain stan-
ues-uk-now-big-drawing-card) and in Kenya, a dard, implementation of those standards may not
massive strike among doctors demanding better be possible in their country of origin either due to
working conditions has left millions of people political uncertainty, geopolitical, cultural influ-
without access to any government provided ences or financial uncertainty. This is more sig-
health care (https://www.bbc.co.uk/news/world- nificant in countries that have been involved in
africa-39271850) and this situation has only war for many years. The author’s visits to such
recently been resolved. countries have demonstrated a high level of skill
The global shortage of health workers is get- of the workforce comparable to internationally
ting worse [7]. In many countries, doctors, nurses, acceptable standards but an impossible task of
midwives and others are left to burn out in bad implementation of those standards as a result of
working conditions—or leave their countries in some cases a complete breakdown of struc-
altogether—countries and their communities suf- tured society creating a total lack of clinical and
fer then from loss of front line staff creating a administrative/operational level organisation.
negative spiral into lower-quality care. The current conflict in Syria is a prime example
Organisations are working to change this, but of this as skilled surgeons function in make shift
it will take time, investment, different ways of accomodation [8].
thinking and a new generation of aid.
Proper management of human resources is
critical in providing a high quality of health care.  ccessibility and Rationalisation
A
A refocus on human resources management in of Healthcare Services
health care and more research is needed to
develop new policies. Effective human resources On a global scale, hospitals vary in size from
management strategies are greatly needed to polyclinics providing basic levels of care to large
achieve better outcomes from and access to multi specialty hospitals. Continuing on from the
health care around the world. theme of patient demand and supply as well as
Internationally the recruitment and retention the increasing costs of running a hospital, closing
of healthcare professionals is becoming more dif- smaller units or departments within units (more
ficult year on year as demand continues to out- so within government sponsored organisations
strip supply in competition with what are seen as like the NHS) has been considered causing much
more lucrative less pressured forms of employ- public outcry. Centralisation of very specialised
ment in areas such as IT. services is also an increasing feature of the ratio-
In the U.K. the Brexit conundrum has left nalisation of services to maximise expertise and
many of the European workforce uncertain of reduce the financial burden.
their longer term futures within the U.K. thereby
exacerbating the existing shortages in nursing
and medical workforce within the NHS. Quality and Outcome Measures

The focus of any healthcare system is on the

Medical Education quality of the service provided and the outcome
measures of the interventions. This unfortunately
The number of overseas students accessing uni- is lacking in many developed countries where
versity placements in U.K. gives opportunity to healthcare outcomes lag behind developed coun-
provide U.K. standard education in countries of tries [9]. In the U.K. the National Health Service
origin. Establishing the delivery of training stan- has developed a ‘safety thermometer’ which has
dards equivalent to but outside of U.K. is a chal- to be reported on a monthly basis. Pressures
10 T. Tomlinson and P. Godbole

sores, incidence of MRSA or other hospital failure by senior management to act on patient
acquired infections, C. Difficile, Deep vein feedback or feedback from the hospital staff [11].
thrombosis are a few of the general outcomes that While the challenges are daunting, health
have to be reported (https://www.safetythermom- challenges require active involvement of all lev-
eter.nhs.uk). Furthermore there has become a els of government (international, national, and
trend towards outcome reporting for certain key local). In an interdependent world, the need to act
specialties which are available by individual spe- together on health challenges and on the determi-
cialist in the public domain. This is not the case nants of health becomes ever more important.
globally. There are very few standard outcome A partnership-based vision is required engag-
measures reported on a consistent basis to allow ing with governments, nongovernmental organ-
for comparison or quality assurance of the health isations, civil society, the private sector, science
systems on an international platform. With the and academics, health professionals, communi-
advent of the U.K. National Institute for Health ties—and every individual citizen. How strongly
and Clinical Effectiveness (NICE) (https://www. leadership of this process emerges holds the key
nice.org.uk) emphasis is being increased on clini- to future step changes.
cal interventions which are effective and provide
value for money. Increasingly commissioners of
healthcare are using the guidelines published by Global Healthcare Opportunities
NICE to effectively ration intereventions. This
has been the case in terms of the surgical treat- Investment
ment of varicose veins some 10 years ago.
However, a gradual increase in the number of There is an increasing trend where countries with
varicose ulcers requiring long term often costly high economic growth enlist the assistance of
treatment is leading to a rethink in this strategy. reputed internationally recognised organisations
to provide and improve the quality of healthcare
in their region. The investment in this infrastruc-
Patient Centric Healthcare ture may be by the government themselves or by
non governmental organisations (NGO) [12].
There is no doubt that all healthcare providers The GCC countries is an example of this invest-
would agree that it is not only the outcomes that ment. The United Arab Emirates has seen an
matter to the patients but also the overall patient explosion of healthcare facilities with interna-
experience [10]. Increasing awareness and tional collaboration.
knowledge amongst patients and their expecta- The National Health Service has recognised
tions should be catered to as ‘customers’ of the this opportunity of exporting it’s brand with the
hospital. This awareness is increasing with aim of improving the quality of healthcare inter-
increased reliance on social media. Feedback nationally. Individual NHS Trusts may aim to do
from patients is important and constructive criti- so as part of their strategic vision for international
cism is desirable. A willingness of healthcare growth and a new revenue stream. Independent
providers to act on this feedback is essential to organisations may provide quality assurance sys-
maintain the quality of the service. Feedback tems as part of turnkey solutions to new hospital
from the workforce providing the service is also development projects with the aim of ‘getting it
essential. A demoralised workforce will not nec- right the first time’. The authors have experience
essarily provide the best quality of treatment. In of the latter in the GCC countries, Sub Saharan
the National Health Service, the Friends and Africa and Far East Asia where there is an appe-
Family Test (FFT) (https://www.england.nhs.uk/ tite and drive for healthcare improvement. The
fft/) has been introduced as a comparator amongst Moorfields eye hospital, an NHS Trust in London
NHS organisations. Where hospitals have failed, U.K. established a satellite hospital in Dubai in
a root cause analysis has demonstrated a chronic 2007, permanently staffed and providing
2 Opportunities and Challenges in Global Healthcare 11

o­utpatients and day care services for patients name a few. The second priority is to develop
with eye conditions. The staff provide a high research strategies to tackle the growing prob-
quality care at par with their U.K. parent hospital lems with smoking, obesity, diabetes and cardio-
standards. They have undertaken over 30,000 vascular disease. The final priority is development
patient episodes from the UAE and wider Middle of new technologies and treatments. International
East and are also active in research and educa- collaboration in research studies and multi insti-
tion. In the U.K. organisations like UKIHMA tutional clinical trials are a significant opportu-
(U.K. International Healthcare Management nity for independent researchers and research
Association) (http://www.ukihma.co.uk) pro- institutes to promote health and well being glob-
vides links between U.K. organisations and over- ally [14].
seas clients. The UK Export Finance department
(within the U.K. Treasury department) facilitates
government to government loans or supports Careers
organisations with capital funding to provide
healthcare services internationally. This trend is Organisational opportunities in international
set to continue for the foreseeable future with the markets has already been referred to above. Hand
most recent budget (October 2018) providing an in hand with this is the opportunity to develop
additional £2 billion towards UKEF funding and enhance one’s career. It is well known that
going forward [13]. markets such as the Philippines and India ‘export’
high quality nurses overseas, especially in the
Middle East giving them the financial stability
Teaching and Training and career trajectory that may not be available in
their own country. Similarly opportunities for cli-
With the provision of international healthcare nicians and allied healthcare workers are signifi-
services, there is a significant element of teaching cant in the healthcare market. With ease of travel
and training. This is not only in the sphere of making no destination in the world out of bounds,
clinical practice but also operational manage- more and more doctors are able to undertake fur-
ment of hospitals and in some instances com- ther training overseas or provide their expertise in
mences from the concept and design phase of a markets where this is required. This also brings
new hospital project through to operational man- the opportunity to have a career, certainly as a
agement. Clinical teaching and training is well Physician or surgeon which spans more than one
established with specialists in their field being country or continent.
sought after to visit established institutions
abroad to develop the skills framework for that
institution specifically but the region at large. In Conclusion
the author’s experience, this teaching and train-
ing has been very well received and disseminated International healthcare provision remains a
to the workforce to ensure sustainability of the challenge in terms of accessibility, finance, cost
teaching program. effectiveness, patient demand and consistency of
outcomes. There remains significant variability
in the delivery of patient care to a basic minimum
Research standard and quality. Healthcare needs to be more
patient centred, evidence based and transparent.
There are three global priorities in global Numerous opportunities exist to achieve these
research. The first priority is to undertake research deliverables; however, these require close gov-
and service delivery of key basic healthcare needs ernment to government relationships and a will-
namely clean water, sanitation, food, mosquito ingness to put healthcare at the forefront of key
nets, maternal and child welfare, vaccines to priorities.
12 T. Tomlinson and P. Godbole

References 8. Kherallah M, Alahfez T, Sahloul Z, Eddin KD, Jamil

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OECD. Available at http://www.oecd.org/general/
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7. Darzi A, Evans T. The global shortage of health
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2016;388(10060):2576–7.
 Part II
Models of Healthcare Provision
 Models of Healthcare
in Developed and Developing 3
Countries

Prasad Godbole and Matthew Kurian

Introduction workers are employed by the government.

Salaries are fixed and costs of treatments are
There are about 200 countries in the world all of standardised. In private hospitals that provide a
whom deliver healthcare to their population. service free at the point of delivery, the hospitals
Although there are 200 countries, the models of get paid by the government. As the government is
healthcare delivery can broadly be classified into the sole payor of all costs of healthcare treatment,
four basic models. it can control what the doctor can do and what the
hospital can charge. This ‘general taxation’
model or a variation of this model is favoured in
The Beveridge Model Great Britain, Scandinavian countries, New
Zealand and Spain [1].
The report by William Beveridge during the time It is thought that having a central single sys-
of the Second World War (The Beveridge Report) tem of general taxation ‘under one roof’ would
(https://www.parliament.uk/about/living-heri- bring efficiencies to the healthcare delivery due
tage/transformingsociety/livinglearning/coll-9- to economies of scale. However while this may
health1/coll-9-health/) advocated a proactive be possible in theory due to less bureaucracy and
approach by the public sector in promoting health administrative burden [2], in practice it is far
of the people. The report became the foundation from true. As part of the government, any admin-
for the creation of the National Health Service istrative shortfalls within the government is likely
(NHS), amongst the first health care system, free to be to some degree replicated within the health-
at the point of delivery and funded by tax. In this care sector [3].
system, the healthcare is funded from general Furthermore financing of the healthcare service
taxation, like any other public service like the through general taxation can be challenging. With
police force or community libraries. Most hospi- an ever increasing age of the population and
tals are government owned, and most healthcare increase in chronic diseases, more money needs to
be found to fund this. Raising taxes is never a pop-
ular option with governments who therefore have
P. Godbole (*) to somehow economise in their service delivery.
Department of Paediatric Surgery, Sheffield In the NHS, the National Institute of Health
Children’s NHS Foundation Trust, Sheffield, UK and Care Excellence (NICE) (https://www.nice.
e-mail: Prasad.Godbole@sch.nhs.uk
org.uk/), provides guidance on best practices
M. Kurian against which hospitals are scrutinised for com-
Doncaster and Bassetlaw NHS Foundation Trust,
Doncaster, UK pliance. Furthermore NICE can play the role of

© Springer Nature Switzerland AG 2019 15

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_3
16 P. Godbole and M. Kurian

gatekeeper in determining which treatments are deductions and covers the entire population. In
cost effective and should be provided. Germany there are approximately 240 insurers,
While the patient never receives a bill, rationing however contrary to the USA, these are not for
to some extent of healthcare services may preclude profit. Due to the tight regulatory control by the
some patients from receiving ‘non urgent or non Government, there is much better control over
essential treatment’. Decentralisation and devolv- costs. In most cases, at least a significant propor-
ing of the budgets and decision making to local tion of the costs of the patient are reimbursed
authorities and municipalities and councils may through these schemes. Most people will get
increase this rationing and may encourage those additional private insurance to cover the top up
who can afford it to pay out of pocket for their reimbursement costs. While this is primarily
treatment. In the U.K. Clinical Commissioning aimed at employers and employees, those with-
Groups led by primary care practitioners, non clin- out jobs are supported by the government to get
ical managers and senior nurses are a prime exam- complete coverage.
ple of this. It has become apparent these groups are However the risk of this model is the burden
many a times conflicted between cost saving, per- of tax on the employed population. In countries
sonal views and implementing what is seen as the such as Belgium and France, the tax wedge on
best for the population. As a result certain groups labor income is significant and can make the
have no service, and others have a greater focus. countries less competitive in the international
Conditions such as varicose veins, simple uncom- market for attracting inbound employment [6].
plicated hernia repairs are not routinely funded
unless by exception. This has gradually increased
during the last decade and the prolonged period of The National Health Insurance Model
austerity, a far cry from the previous decade when
the Labour government opened the taps on spend- This system has elements of both the Beveridge
ing in the NHS. and Bismarck Model. Every citizen pays into a
Earmarking specific areas of general taxation government sponsored insurance program and
has been used to fund the general taxation model. healthcare is provided in the private sector [7].
For example in Australia the tax on tobacco is Canada is a leading example of this system and
ploughed back into the healthcare system (https:// the healthcare coverage is universal. As every
www.dailymail.co.uk/news/article-5712033/ citizen pays into the insurance program, there is
How-smokers-paying-nations-health-care- no need for marketing or any incentives to deny
17billion-paid-tobacco-taxes.html) and has been any claims. Furthermore as a single payor, this
for a number of years. A similar earmarking can drive down costs through negotiations with
arrangement is also in place in countries like vendors most notably in the pharmaceutical
Portugal, Finland and South Korea. In Brazil, the industry. While this system works, it may not
Unified Health System established in 1988 brought cover every condition and there is a likelihood
a huge population without healthcare into the fold. that patients may have to wait longer to be seen
However chronic underfunding, lack of adequate or to have treatment. Apart from Canada, Taiwan
workforce and equipment shortages have led to and South Korea are emerging markets that uti-
lengthy waits and for those with money to opt for lise this model [8].
private insurance based healthcare [4].

 rivate Insurance and Out

P
The Bismarck Model of Pocket Model

Most notably found in Germany [5] this model is In many of the developing countries there is a vast
funded by an insurance system. Financing is pro- gulf between the rich and the poor. In countries
vided by employers and employees through payroll such as India, those with adequate finances can
3 Models of Healthcare in Developed and Developing Countries 17

avail of the numerous private hospitals for their with ill health and can afford to do so are likely to
healthcare. In the 1980s there were only two take out private insurance policies for their
options for healthcare in India. One was the gov- healthcare and more likely to claim for this
ernment owned hospitals and the other was pri- thereby increasing the premium for healthy indi-
vate healthcare for profit facilities. However over viduals with private insurance.
the last two decades there has been an insurgence In the U.K. private health insurance may be
of private insurance providing healthcare cover self funded or through employers. Self pay pack-
for those who can afford it [9]. However, those ages for treatments are also available. However in
who are extremely poor or who have no or little some instances, private or self pay initial consul-
access to healthcare have to somehow find the tations may be requested with a view to bypass-
means to pay for their healthcare. Many of those ing the wait for an outpatient appointment and
who are unable to afford healthcare or do not have potentially (but not necessarily ethically) fast
the means to access any healthcare either suc- track their subsequent treatment in the public
cumb to their illness or as in the past pay for sector. Many developing countries have to some
healthcare by other means (paying in livestock is degree a combination of out of pocket and private
not unheard of even today). To maximise cover- insurance healthcare model. However the major-
age of healthcare, the concept of corporate social ity of the global population where healthcare
responsibility is in place in India where big corpo- infrastructure is scarce, the government in tur-
rate organisations have by law to set aside a sum moil or in crisis, in war torn regions, the out of
of money for infrastructure projects such as pocket model remains in place for millions of
healthcare [10]. This health paradox in India is as people.
diverse as the country and its different ethnic
groups. It is served by traditional health resource,
homeopathy and Ayurveda, and more conven- What about the U.S.A.?
tional allopathic system. This is delivered by a
poorly resourced and managed Government ser- The United States is exemplified by a somewhat
vice, and a very advanced technology supported disjointed delivery of healthcare using all four
private health service. The private health service models. The U.S.A. has the highest per capita
compares with the best in the world, and attracts expenditure on healthcare than any of the OECD
health tourists from Europe and Africa. It even countries [11]. A large proportion of healthcare
boasts of an organ transplant service sponsored by costs are spent on administration of insurers [12].
Corporate business houses. Population growth, Americans with higher wages may get their
and female literacy are the biggest challenges to insurance through their employers or privately.
delivery of health. The state of Kerala, that boasts Figures show that employers with a high number
100% female literacy, has health parameters that of low paid employees are less likely to provide
can compare with the best in the world. Assistance insurance benefits than those with a low number
of voluntary organisations, in health delivery, has of low paid employees [13]. The Affordable
helped eradicate polio from the country. Care Act (https://www.healthcare.gov/glossary/
It has long been thought that by encouraging affordable-care-act/) has enabled those on low
private insurance would lessen the burden of wage to get insurance or to shop around for insur-
healthcare provision on governments. However ance in the marketplace. However over the years
most private insurers are for profit and hence can the cost of healthcare and insurance premiums
decide to refuse coverage for preexisting condi- has increased. This is attributed to the longevity
tions or other conditions with a view to minimis- of the population and the increase in chronic
ing claims and maximising profit. Furthermore, it debilitating diseases such as obesity and diabetes.
is likely that doctors may over investigate or pre- This rising cost of healthcare quite often prohib-
scribe for insured patients on the assumption that its people from either not seeing a healthcare pro-
the insurer will pay for it. Furthermore, those vider or delaying treatment or filling in a
18 P. Godbole and M. Kurian

prescription. After the ACA, there still remains world. Models vary from out of pocket, insured
almost 32 million of the American population or government funded or a hybrid. Unfortunately
that remain uninsured [14]. vast numbers of people still do not have access to
This system it is claimed does not put the patient affordable healthcare and governments need to
at the heart of the service. It is served to a large work hard to make this a priority.
extent by insurers most of whom are for profit.
Unnecessary tests are often done to avoid litigation,
and the profits may be shared with the doctors. References
The ethnic minorities, who live in the poorer
neighbourhoods, have high mortality and mor- 1. Tax-based financing for health systems: options
and experiences. Discussion paper number 4. 2004.
bidity. Visiting Atlanta, the home of Martin Available at http://www.who.int/health_financing/
Luther King, the author (MK) found the town taxed_based_financing_dp_04_4.pdf.
divided with the rich having access to a fully 2. Reynolds E. Look at healthcare models around
equipped private facility, and the ethnic minori- the world. Focus Economics; March 2018.
Available at https://www.focus-economics.com/
ties to a ill equipped hospital across the road, all blog/a-look-at-healthcare-models-around-the-world.
in the same city. 3. Institute of Medicine (US) and National Academy of
Engineering (US) Roundtable on Value & Science-­
Driven Health Care. Healthcare system complexities,
impediments, and failures. In: Engineering a learn-
 ow Can Governments Choose
H ing healthcare system: a look at the future: workshop
the Best Model of Healthcare? summary. Washington, DC: National Academies
Press; 2011. p. 117–70. Available from: https://www.
Where governments have crumbled or the state ncbi.nlm.nih.gov/books/NBK61963/.
4. Massuda A, et al. The Brazilian health system at
infrastructure is in disarray, choosing the correct crossroads: progress, crisis and resilience. BMJ Glob
healthcare model can be difficult. Many a times, Health. 2018;3(4):e000829.
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political rivalry and infighting. Much less impor- a bit of Bismarck plus more science. BMJ.
2008;337:a1997.
tance is given to considering the needs of the 6. Chung M. Healthcare reform: learning from other
people, current cultural and structural organisa- major healthcare systems. Princeton Public Health
tions within the society at these times and more Review. 2017. Available at https://pphr.princeton.
on delivering any ‘model’. In 2002 in Afghanistan, edu/2017/12/02/unhealthy-health-care-a-cursory-
overview-of-major-health-care-systems/.
a decision was made to privatise healthcare due 7. Lorraine LS. A view of health care around the world.
to the preponderance of NGO’s prevalent in the Ann Fam Med. 2013;11(1):84.
country with very little thought on building up 8. Lee SY, Chun CB, Lee YG, Seo NK. The National
the healthcare infrastructure from grass roots Health Insurance system as one type of new typology:
the case of South Korea and Taiwan. Health Policy.
level [15]. It was felt that by providing such a 2008;85(1):105–13.
model all the other problems would heal them- 9. Anita J. Emerging health insurance in India - an
selves. Similarity in Iraq, after the recent turmoil overview. 10th Global Conference of Actuaries.
and change in government, there is very little h t t p s : / / w w w. a c t u a r i e s i n d i a . o rg / d ow n l o a d s /
g c a d a t a / 1 0 t h G C A / E m e rg i n g % 2 0 H e a l t h % 2 0
progress in delivering a healthcare service for the Insurance%20in%20India-An%20overview_J%20
people that meets the standards. Many hospitals Anitha.pdf.
remain in ruin, fully equipped but not operational 10. Balch O. Indian law requires companies to give 2%
or partially finished [16]. of profits to charity. Is it working? The Guardian; 5
Apr 2016. Available at https://www.theguardian.
com/sustainable-business/2016/apr/05/india-csr-law-
requires-companies-profits-to-charity-is-it-working.
Conclusion 11. OECD. Health at a glance 2015. OECD Indicators.
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oecd-ilibrary.org/social-issues-migration-health/
Healthcare is a basic right for all people globally. health-at-a-glance_19991312.
There remain vast differences in affordability of 12. Jiwani A, Himmelstein D, Woolhandler S, Kahn
healthcare in the developed and developing JG. Billing and insurance-related administrative costs
3 Models of Healthcare in Developed and Developing Countries 19

in United States’ health care: synthesis of micro-­ U.S. Census Bureau. Washington, DC: Government
costing evidence. BMC Health Serv Res. 2014;14:556. Printing Office; 2015. p. 5.
https://doi.org/10.1186/s12913-014-0556-7. 15. Sabri B, Siddiqi S, Ahmed AM, Kakar FK, Perrot
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 Part III
Provision of Effective, Safe and Good
Quality Care
 How Do Hospitals Deliver Safe,
Effective and High Quality Care? 4
Patrick Dobbs

Over the years there have been several methods Effective Effective means that people’s care,
to assess whether care given in a hospital set- treatment and support achieves good outcomes,
ting is safe. As healthcare scandals have promotes a good quality of life and is based on
occurred such as in Bristol paediatric heart sur- the best available evidence [3]. Effective also has
gery [1], or general care in Mid Staffordshire meaning relating to how an organisation uses its
NHS Trust [2] both healthcare regulators and resources to provide safe and effective care, the
service providers have desired improved meth- appropriate use of inputs (staff, equipment and
odology to assess not only safety, but also the medicines) at the lowest cost (economy) to
effectiveness and quality of care provided to achieve the best mix of high quality outputs
patients and their families. This chapter will (patients receiving treatment) [5].
review how hospitals that are recognised for
safe, effective and high quality care have done High Quality Quality is a more nebulous con-
so, and how their lessons are shared to the wider cept in the healthcare setting in that it is the over-
healthcare community. arching feature that encompasses other indicators
It is important to understand what the terms of care. The World Health Organisation (WHO)
safe, effective and high quality mean in the con- defines quality as: “the extent to which health
text of a healthcare setting: care services provided to individuals and patient
populations improve desired health outcomes. In
Safe Safe means that people are protected from order to achieve this, health care must be safe,
abuse and avoidable harm (abuse can be physical, effective, timely, efficient, equitable and people-­
sexual, mental or psychological, financial, centred” [6].
neglect, institutional or discriminatory abuse)
[3]. Emphasis is placed on the system of care Combining the above definitions it can be
delivery that prevents errors; learns from the considered that safe, effective and high quality
errors that do occur; and is built on a culture of care is when a patient receives the best evidenced
safety that involves health care professionals, treatment, without complications, efficiently
organizations, and patients [4]. through quicker recovery and shorter lengths of
stay using appropriate resources.
Historically hospital safety was judged through
crude markers such as mortality rates; these
P. Dobbs (*) assumed homogeneity within healthcare organ-
Sheffield Teaching Hospitals NHS Foundation Trust, isations and could offer false assurance from
Sheffield, UK
e-mail: Patrick.Dobbs@sth.nhs.uk favourable results. However variation in mortality

© Springer Nature Switzerland AG 2019 23

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_4
24 P. Dobbs

rates cannot be ignored, as they might indicate Each service was rated against the metrics of
unacceptable variation in healthcare and avoid- Safe, Effective, Caring, Responsive and Well
able mortality, but they also cannot be reliably Led, the ratings being on a four point scale,
used to judge the quality of healthcare, based on Outstanding, Good, Requires Improvement and
current evidence [7]. This view was echoed by Sir Inadequate. These ratings are aggregated to pro-
Robert Francis “it is in my view misleading and a vide an overall hospital rating as in Table 4.1.
potential misuse of the figures to extrapolate from The ratings provide a snapshot in time of the
them a conclusion that any particular number, or quality of care at core service, hospital and trust
range of numbers of deaths were caused or con- level [3].
tributed to by inadequate care” [2]. It can be seen that the CQC inspections uncover
Following the publication of Sir Bruce Keogh’s variable practice within the same organisation, so
report into care at 14 failing NHS trusts [8], the even hospitals rated outstanding overall may have
Care Quality Commission began examining in areas rated as requiring improvement.
depth all NHS acute and specialist trusts across a The inspections when aggregated also provide
range of metrics. This review summarised in the new information regarding patient safety; Fig. 4.1
report “The state of care in NHS acute hospitals: shows the relationship between CQC ratings and
2014–2016” [3], is the most comprehensive exam- financial performance.
ination of a healthcare system yet and is able to It can be deduced that hospitals rated as out-
describe at service and organisational levels what standing often do better financially than hospi-
safe, effective and high quality care looks like. tals rated as providing at a lower level. The
The CQC inspections involved a review of hypothesis for these findings is that hospitals
eight key services: that provide safe and effective care do not have
the financial burden for prolonged lengths of
• Urgent and emergency services stay and additional diagnostics, care and treat-
• Medical care ments when harm occurs.
• Surgery The CQC inspections concluded that there was
• Critical care commonality between organisations that per-
• Maternity and gynaecology formed well, this can be summarised in Fig. 4.2.
• Services for children and young people In practice all six features are closely inter-­
• End of life care related and each requires aspects of the others to
• Outpatients and diagnostic imaging succeed.

Table 4.1 An example of how the CQC rate a healthcare organisation

Safe Effective Caring Responsive Well led Overall
Urgent and emergency Good Good Good Good Good Good
services
Medical care Good Good Good Good Good Good
Surgery Good Good Good Good Good Good
Critical care Good Outstanding Good Good Outstanding Outstanding
Maternity and Good Good Good Outstanding Outstanding Outstanding
gynaecology
Services for children and Good Good Good Good Good Good
young people
End of life care Good Requires Good Good Requires Requires
improvement improvement improvement
Outpatients and Good Not rated Good Good Outstanding Outstanding
diagnostic imaging
Overall Good Good Good Good Outstanding Good
Adapted CQC ratings for Sheffield Teaching Hospitals NHS Foundation Trust [9]
4 How Do Hospitals Deliver Safe, Effective and High Quality Care? 25

£20

£10

£0
Inadequate Requires Good Outstanding
£Millions

Improvement
(£10)

(£20)

(£30)

(£40)
CQC Rating v Forecast Outturn for 2016/2017

Fig. 4.1 The relationship between CQC ratings and financial performance of Healthcare Organisations. Adapted from
The State of Care In NHS Acute Hospitals 2014–2016 [3]

Fig. 4.2 Features of a high performing

organisation
Leadership

Responsive

Culture

Monitor

Share &
Learn

Leadership tinues to all levels of the organisation. The board

is responsible for ensuring:
It is clear that for an organisation to provide safe,
effective and high quality care there must be • The quality and safety of health services.
effective and visible leadership throughout the • That resources are invested in a way that deliv-
organisation. This starts at board level, and con- ers optimal health outcomes.
26 P. Dobbs

• In the accessibility and responsiveness of Responsiveness

health services.
• That patients and the public can help to shape Responsiveness or agility in healthcare relates to
health services to meet their needs. the ability of an organisation to react and adapt
• That public money is spent in a way that is quickly and successfully in the face of rapid
fair, efficient, effective and economic [10]. change [15]. This may be in relation to a sudden
influx of patients, changes in staff levels or
The CQC has found that in hospitals rated national agenda items such as finance. Healthcare
good or outstanding, the trust boards actively in general does not like change, and despite mul-
engaged with staff to determine how the organ- tiple efforts to improve, across the system there is
isation needed to improve. The composition inertia [16] and a reliance on previous experience
and capabilities of the board have been shown to deal with times of stress.
to influence the ability of the board to engage Responsive health systems anticipate and
with staff, and to encourage reporting and han- adapt to changing needs, harness opportunities to
dling of patient safety issues [11]. Jones et al. promote access to effective interventions and
state that boards with mature quality improve- improve quality of health services, ultimately
ment (QI) cultures had strong clinical leader- leading to better health outcomes [17].
ship and engaged staff and patients [12]. Responsiveness also means that services are
Moreover objective data presented to boards organised to meet people’s needs [18]:
was enhanced by softer subjective data gleaned
by clinical leaders from their encounters with • Services are planned for the population they
staff in the clinical scenarios. These boards serve;
were also skilled in balancing short term exter- • Care is coordinated with external agencies;
nal priorities with the needs of their own long • Care is available when needed, without undue
term improvement initiatives [13]. There is delay;
increasing stress at executive level, with shorter • Complaints and concerns are taken seriously
tenures and increasing vacancies in trusts expe- and dealt with in a timely manner. Lessons are
riencing the most challenged levels of perfor- learnt from complaints
mance. Trusts rated as ‘inadequate’ by the Care
Quality Commission had 14% of posts vacant, When services are designed to serve the popu-
compared to only 3% in trusts rated as ‘out- lation using them, they are more likely to provide
standing’. This has a knock on effect on staff a better patient experience which is associated
who feel their leaders have less credibility, and with better health and financial outcomes [19].
also delays organisational progress [14].
Therefore consistent and lasting leadership at
board level would seem important for an organ- Culture
isation to provide quality care.
Whilst leadership from the boards is essential, Good leadership is the foundation for organisa-
it is equally important that consistent leadership tional culture. Baker [20] describes high per-
is in place at every level of the organisation. One forming international organisations whose
reason given for the variability in quality within leaders commit to building a professional culture
high performing organisations is poor leadership that encourages improvement, patient engage-
in certain areas. This leadership must be values-­ ment and teamwork. Organisations rated as out-
driven and coupled with a learning culture to pro- standing by the CQC exhibited cultures that were
vide high quality care [3]. open and honest, where staff were listened to
4 How Do Hospitals Deliver Safe, Effective and High Quality Care? 27

about safety concerns and the board sought the Salford Royal NHS Foundation which has been
views of patients and staff in ways in which the rated as outstanding in successive CQC visits has
organisation could improve [3]. some of the highest staff engagement scores. There
In Sir Robert Francis’s review of creating an is no magic bullet to improve culture and staff
open and honest reporting culture within the engagement. However having a set of core values
NHS, Freedom to Speak Up [21] he defines what and beliefs which put the patient first, are led by
good looks like in a safe culture as: the board and practised by all staff would seem to
be important. The King’s Fund [23] has suggested
• Culture of safety—a move away from blame six building blocks that over time will help to
to just, where safety questions are asked and improve and harness staff engagement:
addressed and learning gained from the
process. • Develop a compelling, shared strategic
• Culture of raising concern—A shared belief direction
at all levels of an organisation in speaking up • Build collective and distributed leadership
about concerns, and supporting those who • Adopt supportive and inclusive leadership
do so. styles
• Cultures free of bullying—bullying inhibits • Give staff the tools to lead service
the freedom to speak up and is counter to the transformation
concept of a just culture. • Establish a culture based on integrity and trust
• Culture of visible leadership—authenticity of • Place staff engagement firmly on the board
leaders at all levels in espousing the values agenda
and beliefs of the organisation is paramount to
the nurturing of a safety culture.
• Culture of valuing staff—recognising the The ultimate test of a vision has to be
value in raising concerns and supporting staff whether it transcends the mission statement
leads to better staff engagement. NHS staff and enters the organisation’s blood-
surveys have shown improved staff engage- stream—the rites, rituals, cultural norms
ment leads to better patient outcomes and and stories about ‘how we do things around
financial performance. here’. In November 2014, staff at
• Culture of reflective practice—allowing staff Wrightington, Wigan and Leigh NHS
to reflect on issues, systems and learning from Foundation Trust wheeled a 77-year-old
incidents. cancer patient into the hospital car park to
say goodbye to the horse she had cared for
Staff engagement is a good mirror of the cul- for more than 25 years. For staff, the mes-
ture within an organisation and there is compelling sage from the story is clear: this is an
evidence that quality of care, patient experience organisation that really is trying, as it
and mortality are directly related to staff engage- claims in its mission statement, to put
ment. Unfortunately the corollary of this is also patients ‘at the heart of everything we do’,
true, where there is poor engagement, where staff and is giving staff the freedom and support
do not feel valued, care suffers [22]. During the to translate the vision into practice.
mid-2000’s Mid Staffordshire NHS Foundation
Trust had some of the lowest staff engagement
scores in the NHS, a period associated with a lack
of quality, safety and compassion. Conversely Case Study adapted from the King’s Fund [23].
28 P. Dobbs

Sustaining and embedding QI initiatives and involving as many staff as possible in making
staff involvement into the organisations culture small improvements in their own areas, with the
can be problematic. Several organisations have aim being to build up a culture of improvement.
adopted varying methods to ensure that initia- It provided:
tives become “business as usual”. The following
are examples from NHS Employers [24] where • The opportunity to share ideas for
sustained improvement has become ingrained improvement
within the culture of the organisation: • The opportunity for frontline staff to become
change champions
• Developmental opportunities.
Sheffield Teaching Hospitals
Hundreds of postcards were submitted with
Developed a Micro Systems Coaching Academy ideas for improvement, and over 40 quality
to support staff to improve in their workplace. improvement projects were launched with a
The aims of the academy are: junior doctor and change champion leading each
one. The top three projects received recognition
• Build improvement capability into the
by the executive team and support to full imple-
workforce
mentation. These and others examples demon-
• Maximise quality and value to patients
strate sustained quality improvement that
• Help multi-disciplinary front-line teams
becomes ingrained to the organisational culture.
rethink and redesign services.

The teams are coached by staff trained in ser-

vice improvement methodology to redesign their
Monitor
services.
For an organisation to know it is safe and pro-
vides quality care it needs to measure and analyse
Tees Esk and Wear Valley its performance. It has already been stated that
simple measures of an organisation such as mor-
This is a specialist mental health organisation and tality rates are crude and insufficient. So what
has a longstanding commitment to staff engage- should an organisation measure and monitor?
ment and service improvement. It started out with External inspections, such as those by the
a focus on Lean methods. It has a large number of CQC provide a snapshot in time, but are an indi-
staff trained in using quality improvement tools, cation of how the organisation performs against a
and recently it has developed a local quality fundamental set of standards of safety and qual-
improvement system (QIS), which emphasises ity [25]. A high quality organisation must con-
that staff know best. The aim of the QIS is to: tinuously monitor and learn to ensure patient
safety and compassionate care. However in 2013
• Analyse existing practice Berwick found “that most healthcare organisa-
• Enable staff to determine what is changed and tions at present have very little capacity to anal-
how yse, monitor or learn from safety and quality
• Provide staff with tools to make change. information” [26].
One approach developed in the UK was to
design a framework for safety encompassing five
 shford and St Peter’s Hospitals NHS
A domains [27]:
Foundation Trust
• Have we been safe in the past?
Be the Change programme was initially devel- • Are systems and processes reliable?
oped by junior doctors. The trust focussed on • Is care safe today?
4 How Do Hospitals Deliver Safe, Effective and High Quality Care? 29

• Will care be safe in the future? • Tier 3 Sustainability of health

• Are we responding and improving? –– Nature of recurrences
◦◦ Maintained functional level
This approach allows an organisation to assess ◦◦ Ability to live independently
and reflect on its past, present and future ability ◦◦ Need for revision or replacement
to provide quality care at organisational level. It –– Long term consequences of therapy
relies on the ability to measure various indicators ◦◦ Loss of mobility due to inadequate
in each domain; however this can be problematic rehabilitation
as most organisations do not collect the required ◦◦ Susceptibility to infection
data in a meaningful way. Furthermore NHS ◦◦ Regional pain
Trusts often rely on too few metrics to assure
themselves on the quality of their services [3]. Adapted from Measuring Health Outcomes
Another approach gaining acceptance in the Michael Porter New England Journal of
US and some European countries is to monitor Medicine [29].
what matters to the patient, based on the values These outcomes can be compared locally,
based healthcare delivery (VBHCD) described nationally or internationally as a driver for qual-
by Porter [28]. In this methodology there is rec- ity improvement.
ognition that existing monitoring is generally of Outcomes measurement has become a science
process compliance with guidelines or headline in itself, national and international cooperation is
values such as mortality rather than the patient’s required in order that consistent and comprehen-
experience. In contrast VBHCD measures out- sive measurement is achieved globally.
comes across three tiers, specific to the disease or This methodology will allow meaningful
intervention at a patient level. For example below comparison to occur and rapid improvement be
would be the outcomes for a hip replacement stimulated.
operation: An international group has been established to
develop and publish agreed outcome measure-
• Tier 1 ments, the International Consortium for Health
–– Health Status achieved or retained Outcomes Measurement (ICHOM) [30].
◦◦ Survival (eg Mortality) However data is collected, it is clear that to
–– Degree of health or Recovery provide high quality and safe healthcare an
◦◦ Functional level achieved organisation must devote resource to continually
◦◦ Pain level achieved monitoring and reacting to the services it pro-
◦◦ Ability to return to work vides. Using benchmarking in an open and trans-
• Tier 2 parent fashion against similar organisations
–– Process of recovery locally, nationally and internationally can only
◦◦ Time to begin treatment drive up quality.
◦◦ Time to return to physical activities
◦◦ Time to return to work
–– Disutility of care or treatment process (eg Sharing and Learning
diagnostic errors, ineffective care, compli-
cations, adverse effects) One of the factors that differentiated hospitals
◦◦ Delays and anxiety rated as outstanding by the CQC from those rated
◦◦ Pain during treatment as inadequate was the culture around how the
◦◦ Length of hospital stay hospitals dealt with safety concerns [3].
◦◦ Infection Unsurprisingly it appears that an organisation
◦◦ Venous thromboembolism/ Myocardial which listens to its staff, has an open and learning
infarction culture and learns from issues raised will provide
◦◦ Need for re-operation better care to the population it serves. Authenticity
30 P. Dobbs

in organisational values and behaviours is criti-

cally important in developing this culture. In the By utilising improvement methodology
NHS all staff have a duty to protect patients from (PDSA cycles) and a bi-directional
harm [31], however staff may be inhibited from approach the National Observatory has
doing so if a blame culture exists. In addition succeeded in implementing a national
some hospitals use incident reporting as a perfor- patient safety initiative that can be trans-
mance management tool which leads to investi- ferable across national and international
gation fatigue and overload of the systems, healthcare systems.
potentially leading to missed opportunities to
learn from patient safety issues [32]. All NHS
organisations must have a system for reporting Case study on National Observatory on Good
near misses and harm, and should examine and Practices [25, 34].
assess if any learning should be gleaned from
incidents. In addition in England and Wales there
has existed since 2003, a National Reporting and Conclusions
Learning System (NRLS), which is a central
database of patient safety incident reports. All No one hospital or organisation will have all the
information submitted is analysed to identify answers to providing the best quality, safe and
hazards, risks and opportunities to continuously effective care for the populations it serves.
improve the safety of patient care [33]. However the hospitals rated highest will have, to
Information is passed back to all organisations in some extent, aspects of all the above factors
a monthly report to disseminate. ingrained into the way they operate. The chal-
Italy has a relatively recent safety policy lenges lying ahead of reduced staff levels (espe-
agenda; set up in 2008 the National Observatory cially nursing), junior doctor’s numbers and
on Good Practices for Patient Safety it is regarded training, and the implications for BREXIT on the
as a model for international health organisations NHS will severely test the ability of organisations
to emulate [25]. to function. Those who demonstrate the values
espoused above have a greater chance of continu-
ing to serve their patients with compassion in a
The National Observatory on Good safe and engaged environment.
Practices for Patient Safety is designed to:

• Address the heterogeneity of care across References

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 Part IV
Identifying Failure
 Transforming Hospital
Accreditation: From Assurance 5
to Improvement

Stephen Duckett and Christine Jorm

Accreditation plays an important role in regula- Although accreditation has been around for
tory oversight of hospitals and other health care almost a century [2], the tried and true formula is
institutions in most advanced economies. under challenge. Participation in accreditation is
Although accreditation started as a voluntary a time consuming and expensive exercise yet the
process, it has evolved in many countries to be overall value of accreditation is unclear. The cur-
effectively compulsory [1]. The formula for rent approach emphasises accountability and
accreditation is common, possibly driven by the assurance rather than improvement, alienating
influence of the international organisation, the many clinicians: when it ignores their priorities,
International Society for Quality in Health Care they dismiss it as irrelevant [3].
(ISQua) which accredits the accreditors. The for- Accreditation is failing and needs to be trans-
mula involves: formed. In this chapter we describe a transforma-
tion path.
• Published standards;
• Hospital visits by ‘surveyors’ to assess the
hospital against the standards; and Data Driven Improvement
• A decision to ‘accredit’ or not.
The main focus of accreditation has been on
The standards generally apply to all organisa- structures surrounding care (process measures),
tions seeking accreditation with little adaption to even though the early twentieth century US sur-
the specific circumstances or performance of an geon whose work stimulated hospital accredita-
individual organization. The same questions tion, Ernest Codman, designed an ‘end results
about infection control, for example, are asked in system’ [4, 5], what we today would describe as
a hospital which has the best performance on an outcomes focus.
hospital acquired infections, as in the worst Accreditation has not kept pace with the dra-
performer. matic improvement that has occurred in hospital
outcomes measurement in recent decades. There
is now a wealth of data collected on patient care,
S. Duckett (*) including most importantly, information on
Grattan Institute, Carlton, VIC, Australia whether diagnoses were present on admission or
e-mail: stephen.duckett@grattan.edu.au arose during the course of the admission [6, 7],
C. Jorm the latter can legitimately be described as com-
NSW Regional Health Partners, plications of care. Routine data, adequately
Newcastle, NSW, Australia
e-mail: Christine.jorm@health.nsw.gov.au

© Springer Nature Switzerland AG 2019 35

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_5
36 S. Duckett and C. Jorm

r­ isk-­adjusted, is now in widespread use in many Risk-based regulation focuses on the highest-­
countries to compare hospital performance [8]. priority risks, determined by assessment of their
Traditional accreditation has not adapted to probability and consequences [16]. There is no
this improvement in the ability to measure hospi- attempt to prevent all possible harms. Ideally,
tal performance. Routine data can be used to low-risk providers are free from the burden of
measure the rarely occurring sentinel events [9], inspection, and inspectors concentrate on organ-
as well as more frequently occurring complica- isations with poor practice. Effective regulation
tions such as hospital-acquired infections [10]. thus controls risk while identifying important
Although these data are not perfect [11], and gen- problems and solving them [17–19].
erally cannot be used to identify complications Responsive regulation assumes the parties being
which are always preventable, they can be used to regulated are trust-worthy and intrinsically moti-
identify comparative performance of hospitals vated [19]. Most effort is therefore put into encour-
[12]. By comparing rates of total complications, aging co-operation (through persuasion) rather
whether those complications can be labelled pre- than enforcing compliance. However, a range of
ventable or not, differences in rates between the enforcement measures of graduated severity must
best and worst hospitals can be used to identify be available (‘the regulatory pyramid’).
opportunities for improvement—when the best Really responsive regulation holds that sensi-
performing hospitals are identified, other institu- tivity to change is central to regulatory
tions can learn from them [13]. performance:
The key transformation required for hospital If regulators cannot adapt to change, they will
accreditation is to shift from assessment of apply yesterday’s controls to today’s problems and
generic one-size-fits-all process-centred stan- … under-performance will be in-evitable [20].
dards to a targeted, hospital-specific approach The emphasis of this approach is on changing
which is data driven. Accreditation should focus measures in response to organisational perfor-
on each hospital’s specific issues in a structured mance. Timely feedback and use of contempo-
and transparent way, to help it hospital respond to rary data means it also allows assessment of the
improvement opportunities. value of the regulation itself:
If regulators cannot assess the performance of
their regimes, they cannot know whether their
Types of Regulation efforts (and budgets) are having any positive
effect in furthering their objectives. Nor can they
Organisations respond to incentives [14]. In justify their operations to the outside world [20].
health care, what is regulated shapes what hospi- A new system of accreditation should be
tals give priority to: really responsive: it needs to adapt to the overall
In healthcare systems, the impetus for change changed measurement environment discussed
can vary from subtle to strident; it can be founded above, the performance of each institution
on fear or on hope; built on pressure to conform accredited and it also needs to build on and rein-
or an imperative to be distinguished; adopt an force hospitals’ and clinicians’ intrinsic motiva-
attitude of support or challenge; can be tacit or tion to improve their safety performance.
codified; and focused or pervasive in scope.
Pressure to change can come from within or from
outside—inducements can take the form of hugs,  roblems with Current Hospital
P
nudges or shoves [15]. Accreditation Systems
Healthcare regulation conveys messages about
what issues are important and how important they Wide variation in complication rates between
are. There are many regulators and regulatory hospitals observed in most countries suggests the
mechanisms. Design of regulation often seeks to accreditation systems have failed [21]. Practically
ensure that it is risk-based and responsive. every significant safety failure in Australia in
5 Transforming Hospital Accreditation: From Assurance to Improvement 37

recent decades has occurred in a hospital which The standards should be linked to important
had passed accreditation with flying colours, and patient outcomes, and unfortunately many cur-
the same is true in many other countries. rent indicators have no clear, evidence-based link
Problems with the current accreditation sys- to patient outcomes [32]. As healthcare is con-
tems have been known for decades, despite regu- tinually changing, indicators should be re-­
lar attempts to improve their effectiveness. What evaluated regularly, including by establishing
little literature there is provides inconsistent and and reassessing links to important patient out-
unconvincing evidence for the value of accredita- comes, and assessing the experience in the best
tion for improving the quality and safety of hospitals, which can be used as benchmarks. The
patient care [22–26]. Only one paper has explic- decision can then be made to ‘retain, revise,
itly sought to explore the potential mechanisms replace, or retire’ them [32]. If links to important
of impact of accreditation [3]. outcomes were not clear when standards were
Denmark recently introduced accreditation and developed it becomes hard to reassess their util-
then rapidly discontinued it for public hospitals ity. However, clear and direct links to important
after claims by doctors and nurses that they were outcomes are not apparent in many current
‘drowning in manuals and paperwork and have no standards.
time for patients’ [27]. Denmark now uses a qual- Another problem with most sets of standards
ity assurance model, based on high-­levels of com- is that while each individual standard may be
pliance with clinical quality registries, using those intrinsically ‘worthy’, the set do not represent
registries to monitor and improve quality [28]. measured solutions proportionate in size to mea-
As part of the accreditation process, hospitals sured patient harms. Correcting this would
compile evidence—such as policy documents, require a comprehensive approach to patient out-
committee minutes, training documents and audit comes, considering what improvements are pos-
results—to show they are meeting the relevant sible, based on the best institutions [13]. Cost
standards. Auditors (or ‘surveyors’) assess a hos- should also be considered: some areas will repre-
pital’s performance during an accreditation visit, sent better investments than others. Understanding
which in Australia is up to 5 days. They examine the cost of complications can also help in ensur-
documents and interview staff. Auditors may also ing appropriate attention to frequently occurring
observe clinical practice and inspect resources, harms, compared to the rare but dramatic adverse
such as signage and personal protective equip- event [33].
ment, but they have limited time available to do Another problem with accreditation is that
this [29]. there are doubts about the validity and reliabil-
An accreditation visit itself results in a period ity of surveyor-based assessments, because dif-
of abnormal care. US research suggests hospitals ferent surveyors provide different opinions
may improve their performance during accredita- [34, 35].
tion visits. One study showed significantly lower Reviews consistently demonstrate doctors’
‘30-day mortality’ for patients admitted during scepticism about accreditation systems [22].
the week of an unannounced accreditation visit Doctors are concerned about the cost of accredi-
than patients admitted in the 3 weeks before or tation programs, their bureaucratic and prescrip-
after the visit [30]. Yet the aim of accreditation tive nature, and the demands made on staff, and
should be to encourage improved outcomes for they believe these programs have no impact on
patients admitted every week of the year. the quality of care. They may feel accountable to
The nature and subject of standards is central themselves, their peers, and their profession, but
to accreditation—they communicate what the not to accreditation bodies [36, 37]. The evidence
regulator thinks is important. There is little evi- shows doctors do not ‘buy-in’ to the accreditation
dence examining the development, writing, process [38].
implementation and impacts of healthcare Additionally, in Australia at least, accreditors
accreditation standards [31]. mostly assess work ‘as imagined’, or as described
38 S. Duckett and C. Jorm

in the ideal case; they do not assess management Table 5.1 Measures to be used in new accreditation
processes
of high-risk situations [29, 39]. This approach in
England has resulted in criticism of accreditation Measure Advantages
for failing to focus on ‘real achievements and Clinical outcome These are important
measures—with an initial objective measures (and
outcomes for patients’, and because of this it has focus on hospital acquired there is no dispute about
been identified as contributing to a major hospital complications (later their value as occurs with
quality scandal [40]. others measures such as process indicators)
Patient Reported
Outcome Measures could
be added)
A New Model for Accreditation Patient experience There is strong evidence
measures linking staff and patient
The failures of the current system are manifold. Staff experience measures experience to clinical
outcomes. These
Radical change is needed.
measures are relevant to
Accreditation needs to move from being an all patient outcomes and
‘event’ in a hospital’s calendar, to being a tool for harms (not just a
a hospital’s continuous improvement. The selection). For more detail
see Duckett et al. [42]
emphasis should move from compliance to
improvement, and from qualitative assessments
against standards to being based on measurable the funder in a public system, or private
change in terms of key dimensions of quality. benchmarking groups.
The accreditation process itself should be more The data should measure three things: clin-
accountable through transparency about who is ical outcomes (at first focusing on hospital-­
doing the accreditation survey and what assess- acquired complications but later adding other
ments are being made. outcomes, including patient-reported out-
Consistent with a really responsive approach comes); patients’ experiences; and staff mem-
to regulation, hospital accreditation should be bers’ experiences. The advantages of each of
reoriented to focus on helping hospitals the three measures are set out in Table 5.1.
improve, rather than simply judging them 2. Each hospital and clinical unit should develop
against ‘standards’. Responsibility for improv- an improvement plan based on its own con-
ing hospital safety should be local, clinically- temporary data.
led and overseen by each hospital’s governance 3. Progress against this plan should be checked
processes, with the accreditation process sup- at least once a year by external accreditors.
porting and assessing a hospital’s progress in 4. Surveyors should spend a day reviewing the
addressing the hospital’s specific safety issues data and plan, and then a day meeting with the
as measured in the data. We propose five strate- Board and senior management. These meet-
gies to encourage a tailored, improvement- ings should focus on assisting the hospital’s
focused approach: own improvement efforts. The whole process
should be about improvement, not blame [43].
1. Comparative data about each hospital’s per- 5. Surveyor assessments of each hospital and
formance should be provided to the hospital at specialty, together with quantitative data such
least yearly. The data needs to be clinically as complication rates, should be made publicly
relevant and sufficiently detailed to allow hos- available. Surveyors should be publicly identi-
pitals to drill down to clinical unit level [11, fied, just as journal reviewers are increasingly
41]. Who should provide the data will vary by expected to be. This would ensure they are
country: it may be a hospital regulatory body, publicly accountable for their conclusions
5 Transforming Hospital Accreditation: From Assurance to Improvement 39

 New Approach to Safety

A Table 5.2 Why transformed accreditation is better than
the current model
Assurance
Problem with current
model Advantage of new model
A safety regulatory system should not be solely
There is a lack of New data sources and
about improvement—safety assurance is still evidence that it improvement plans will help
important. However, in a new model, hospitals improves patient accreditation ‘work’
should self-certify for a set of basic standards, outcomes
or ‘process measures’, with no evidence of audit Standards lack a Major emphasis on patient
strong evidence base outcomes, patient experience
required. This would reduce paperwork and
and staff experience replaces
free-­up independent accreditors to test safety process-based standards—all
and to support hospitals’ improvement activi- have solid evidence
ties. (These basic standards themselves could Different surveyors Comprehensive objective data
occasionally be audited using a risk-based use different methods will be used
Medical staff are not The focus on patient
approach.)
engaged in the outcomes, and the potential
Auditors should make unannounced or short-­ process consequences for poor
notice visits to check on problems or high-risk performance, will ensure staff
situations recently identified elsewhere in the are engaged
state or nation. These hospital visits would not Patient outcomes are Patient outcomes will be
not systematically measured, and safety will be
be about compliance with traditional accredita- measured, and safety tested during unannounced
tion standards, but about testing safety as is in is not tested visits
real-­
life practice in the hospital. It still may There are no The publication of unit-level
involve data, for example, by using evidence incentives for results will encourage
excellence excellence
about hospital acquired infections reported in
Accreditation results Detailed accreditation results
routine data as part of judging whether infection are either not made will be readily available to the
control systems are working in practice. public or are difficult public
to find

The Implications of the New Model Conclusion

Our new model is radically different from current Hospital accreditation internationally requires a
accreditation processes internationally. major overhaul. The current system has proven
Hospital accreditation schemes cost money— ineffective and modifications to it won’t produce
both in terms of direct outlays on fees and prepa- the systematic attention to patient outcomes we
ration time, but also in terms of time spent by need. Our proposed new model replaces a focus
managers and clinicians preparing for accredita- on processes and compliance with minimum
tion which would be better spent on other quality standards with a focus on local patient outcomes
improvement activities. Poor quality care also and improvement. Meaningful local outcomes
costs money, in addition to causing harm [33, will engage clinicians.
44–46]. Therefore a better accreditation scheme Hospitals will no longer be spruced up for an
should be seen as an investment to improve the infrequent planned ‘big event’ accreditation visit.
quality of care and reduce the costs of poor Instead, surveyors will conduct safety tests with-
quality. out notice and provide scrutiny and support for
Table 5.2 summarises the benefits of our new hospital’s improvement work. Attention to the
model of accreditation. operation of a continuous outcomes-data based
40 S. Duckett and C. Jorm

improvement plan becomes the major role of the healthcare? A conceptual framework for levers of
change. BMJ Open. 2017;7(8):e014825.
hospital board. We believe that this proposal will 16. Beaussier A-L, et al. Accounting for failure: risk-­
create a systematic approach to reducing the based regulation and the problems of ensuring
­incidence of all harms to hospital patients and healthcare quality in the NHS. Health Risk Soc.
therefore to reducing the cost of complications. 2016;18(3–4):205–24.
17. Braithwaite J, Makkai T, Braithwaite V. Regulating
aged care: ritualism and the new pyramid.
Northampton, MA: Edward Elgar; 2007.
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 Key Features in Identifying
Failing Hospitals 6
Rivanna Stuhler and Martin A. Koyle

Introduction sionals, government bodies, community partners,

insurers, and, most importantly, patients [1]. Like
Hospitals, unlike other large institutions such as schools, or first-response providers (fire, police,
those in business or industry, are complex organi- or ambulance services for example), hospitals
zations, operating with the goal of meeting mul- operate in complex systems where financial
tiple, often conflicting, missions, in a demanding, health is as much a priority as high quality care
constantly changing environment [1–4]. Many provision, service excellence, and employee
consider healthcare to be a service industry. development. The inherent complexity of the
However, comparisons cannot be made between hospital system means that while lessons can be
other service-based industries such as utility pro- learned from other industries, comparisons
viders (water or electricity), as these industries between the two cannot easily be made [1, 4]. As
are not required to operate in a system with con- an illustration, while a power utility provider is
flicting demands. Their goal is singular in that unable to anticipate profound temperature
they strive to provide their particular service to changes and the necessity for more energy pro-
their customers. Hospitals, on the other hand, are duction to compensate for additional air condi-
accountable to multiple stakeholder groups, tioning in the summer or heat in the winter,
including physicians, nurses, allied health profes- healthcare cannot anticipate fluctuations in dis-
ease prevalence (influenza outbreaks, for exam-
ple) or rapid changes in medical practice. These
R. Stuhler (*)
factors are beyond the control of the utility com-
The Hospital for Sick Children (SickKids),
Toronto, ON, Canada pany and the healthcare provider, but cannot be
equated, as advances in healthcare, while provid-
The Institute for Health Policy, Management,
and Evaluation (IHPME), University of Toronto, ing benefit, may also lead to significant and unex-
Toronto, ON, Canada pected cost, whereas there have been hot and cold
e-mail: rivanna.stuhler@sickkids.ca snaps in the past that the utility provider can look
M. A. Koyle to for guidance. The utility company can use past
The Hospital for Sick Children (SickKids), data to predict what might be needed, but hospi-
Toronto, ON, Canada
tals need a broader and more innovative outlook
The Institute for Health Policy, Management, to succeed, requiring visionary leaders and staff,
and Evaluation (IHPME), University of Toronto,
a culture that supports the vision, and systems
Toronto, ON, Canada
that provide tools and measures that make achiev-
Department of Surgery, University of Toronto School
ing the vision a reality.
of Medicine, Toronto, ON, Canada
e-mail: martin.koyle@sickkids.ca

© Springer Nature Switzerland AG 2019 43

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_6
44 R. Stuhler and M. A. Koyle

In order to meet the unique challenges the about the vision, mission (or missions, plural,
health care system faces, those within the system given the nature of the hospital environment),
must be aware of factors that improve, or worsen, and values of the organization, and understand
performance and provision of care, so as to the benefits of using multiple channels of com-
­mitigate circumstances that can lead to failure in munication to disseminate this message [1, 6,
hospitals, of which there are many. Ideally, these 12]. While they may be committed to ensuring
should be identified early—by front-line staff, that the overall vision and likely multiple mis-
middle management, or those on the senior exec- sions of the hospital are met, good leaders also
utive level—in order to allow for change, have an in-depth understanding of the challenges
improvement, and ideally, success. This chapter in meeting these goals from the perspective of
will examine some of these factors, particularly those on the front-line. This allows them to foster
those within the control and scope of managers the creation of realistic plans for improvement, as
and leaders at all levels throughout the organiza- well as buy-in for these plans from their staff [11,
tion. It is equally important for a manager who 13]. The best leaders, while supportive of their
oversees one or two individuals, or the CEO of staff, are also never comfortable with the status
the hospital, who is responsible for thousands of quo, always looking to improve [8]. They are
people, to be aware of, and comfortable with, the passionate about quality improvement and patient
following factors, as ignorance of these factors safety, and make this subject a true priority, rather
can lead to poor performance and ultimately, fail- than just word speak, at all levels within the orga-
ure [5]. These factors are leadership, culture, nization. By doing this, they encourage all staff,
vision, information gathering and management from the board of directors down to those on the
systems, and planning processes. front-lines, to be involved in well thought out and
cleverly executed improvement initiatives [6, 7,
10, 13, 14]. This focus on improvement is vitally
Leadership important given the ever-changing nature of
healthcare, and the constant pressure to perform
A strong leader is the key to any successful orga- clinically and financially, both from internal and
nization. Traits of good leaders have been widely external stakeholders. An emphasis on safety ide-
studied and reported [2, 6–10]. Mannion, Davies, ally leads to a culture of safety, critical in high
and Marshall (2005) suggest a collection of char- reliability organizations (HROs) such as those
acteristics they regard as key in a strong leader, within the aviation and train transportation indus-
including being visible, approachable, account- tries [15, 16]. Healthcare organizations aspire to
able, and promoting a “can-do” culture in which be like HROs, or indeed, become HROs, where
employees at all levels are encouraged to play a error is the exception rather than the rule, con-
part in changing and improving the organization. stant scrutiny and questioning at all levels leads
Firth-Cozens and Mowbray (2001) further char- to sustained improvement, and where account-
acterize good leaders as intelligent, sociable, ability exists on all levels [16, 17]. Strong leaders
determined, and assertive. Leaders should dem- who exhibit those skills as outlined above, and
onstrate integrity, and while ideally being confi- believe in the ethos of the HRO tend to lead hos-
dent, should also be humble enough to recognize pitals which are higher performing organizations.
and learn from mistakes (their own, or those of Their approach ensures that the hospital is set up
their staff or organization) [7, 9, 11]. They are to succeed as the objectives of the institution are
receptive and responsive to problems within the clearly stated, and plans to meet those objectives
organization, and are openly appreciative of their reasonable and realistic based on the needs of the
employee base, helping develop staff potential organization.
with the ultimate goal of aligning their individual Conversely, underperforming, or failing, hos-
priorities with that of the organization [8]. Strong pitals, are often defined by a lack of innovative,
leaders articulate a clear and consistent message visionary leaders. Keroak et al (2007) looked at
6 Key Features in Identifying Failing Hospitals 45

leadership characteristics associated with high- characteristics exhibited by themselves, their

and low-performing hospitals. Leaders at the top-­ colleagues, and their organizations, that lead to
performing institutions exhibited most, if not all, poor collaboration and communication, and ulti-
of those qualities outlined above. The traits of mately result in suboptimal performance and
leaders in lower-performing hospitals were simi- failure. Leaders who are not self-reflective, who
lar to those discussed by Mannion, Davies, and do not benchmark against the highest perform-
Marshall (2005), most specifically being per- ing organizations, and who reject feedback and
ceived as remote or distant, disinterested, and data that indicate a less than optimal perfor-
intimidating. These leaders did not make them- mance open themselves up to failure. In contrast,
selves visible or approachable, and staff did not those who recognize gaps and deficiencies and
feel them to be trustworthy or exhibit a high work to create a culture of constant improvement
degree of integrity. In these hospitals, leadership with a collective approach to enhancing care are
was not receptive to input from staff, and those more likely to see improvements in performance
who challenged the status quo were perceived as with the added benefit of improved overall cul-
threats and “troublemakers,” and sometimes ture, another factor that can lead to failure in
removed from their posts. Relationships between hospitals.
internal departments, and with external partners
were often antagonistic, with conflicting priori-
ties fighting for recognition, instead of an align- Culture
ment of multiple priorities under the same
overarching organizational umbrella noted in The culture of a hospital is integral to the way in
higher-performing hospitals helmed by strong which the organization works. The type of cul-
leaders [1, 6, 10, 12, 13]. Weaker leaders such as ture, and the qualities prioritized within it con-
these tend to be more autocratic in style, resulting tribute to how well an organization performs.
in organizations that do not welcome collabora- Cultures are unique to an organization, each with
tive change and make decisions based on indi- its own distinctive flavour and qualities. However,
vidual priorities, rather than those of the hospital a high performing organization is more likely to
at large [5, 10, 13]. There is less clarity at the have a strong culture, one that encompasses the
leadership level as to the vision and mission(s) of general qualities of what is seen as a good and
the hospital, and quality improvement (QI) is a productive culture, in addition to those traits dis-
more abstract concept, unconnected to the daily tinct to the organization. Strong leaders tend to
operation of the hospital [10], unlike in high-­ foster strong cultures, as their commitment
performing centres where QI is integrated into towards corporate clarity, all-staff involvement,
every aspect of the organization. Because these and a positive, “can-do” working environment
lower performing hospitals operate within a cul- encourages a philosophy of collaboration, inno-
ture of blame, error is more likely to occur, and vation, creativity, and accountability [6, 17]. Staff
lessons are not always learned from mistakes. members who feel listened to, appreciated, and
Again, the example of the HRO and the radical valued are more likely to perform well, as
improvements in safety that came about with the opposed to those who feel they work in a culture
institution of checklists, other similar tools, and a of blame, are overworked and underappreciated,
shift towards an open and honest environment is and are apprehensive to speak up when issues
relevant [15, 16]. Hospitals run by poor leaders arise due to a fear of punitive measures being
are more likely to be those where error is a con- taken against them [6, 8, 10, 15]. The environ-
stant, and where propagation of an environment ment that the latter group work in breeds cyni-
where failure is more likely to occur is the daily cism, distrust, skepticism, a marked decrease in
reality. perceived work-life quality, and a high tendency
In order to avoid failure, leaders and man- towards poor practice, as challenge, dissent,
agers at every level must be aware of those and an openness to change are taboo within the
46 R. Stuhler and M. A. Koyle

culture [10, 12, 14, 18, 19]. Within these hospi- the same [10]. Accountability on all levels fosters
tals may exist a strongly retained culture of hier- a collective culture that allows for the creation of
archy with strict expectations of loyalty to the a strong and potentially symbiotic relationship
senior executive from management at all levels with internal and external stakeholders, strength-
[2]. In organizations like this, leaders often place ening the links between hospitals and their com-
priority on projects close to their own self-inter- munity providers, as well as enhancing the local
ests rather than looking at the broader needs of health economy [6]. Those working internally and
the organization and prioritizing accordingly externally know that they are respected and val-
[13]. Employees therefore feel disempowered to ued, and so work more positively to meet the col-
create change, collaborate, innovate, or report lective goals of the organization. Thus a just
errors, and may indeed work to a lesser standard culture is the ideal, but not always the reality, as
as a result of overwork, demotivation, and lack of shifts away from more closed and rigidly hierar-
appreciation, potentially leading to institutional chical cultures towards those that are open, hon-
failures [2, 10, 15, 17, 18]. One key element of a est, and collaborative take a very long time, and a
good culture that appears to be lacking in these sustained and concerted effort.
more toxic cultures is a commitment to organiza- Of course not all hospitals have purely “good”
tional accountability, often from the top down. or “bad” cultures. Most organizations have lean-
Accountability is a key component of a healthy ings towards one, but exhibit elements of the
culture. Maintaining accountability is important other. In order to recognize and minimize failure,
on many levels, relating to both staff, and the orga- the type of culture prevalent in an organization
nization itself. Organizational accountability fos- must be recognized by management at all levels.
ters an environment in which staff know that blame Data from employee satisfaction surveys and
will not be placed on them for the failings of the internal or external reviews must be taken seri-
institution [15]. This engenders personal account- ously, and addressed in a timely manner.
ability within the organization, leading to a culture Suboptimal results cannot be ignored, and should
of safety over blame [15, 17], or what is com- be addressed in a manner that fosters real change,
monly referred to as a “just culture.” A just culture both structural and cultural. The best organiza-
is one in which there is a balance between personal tions will use their setbacks as change and growth
and organizational accountability [15, 20]. There opportunities, thus improving the culture [11, 13].
is a focus on reporting of errors in order to allow Results highlighting the successes of an organiza-
for reflection and improvement, as opposed to tion should not be ignored either, as the continua-
placing of blame. In this way, just cultures are also tion of these successes and maintenance of a good
learning cultures, those where safety incidents, and just culture requires ongoing work. To do this
preventable or otherwise, are considered opportu- requires a level of managerial and organizational
nities for improvement [15, 20]. Just cultures pri- humility, a strong institutional vision to aspire to,
oritize safety, and provide cultural infrastructures and a willingness to recognize that there are flaws
that encourage communication, questioning, col- within the structure and culture of the organiza-
laboration, and open and honest reporting [15, 20]. tion that could be improved upon. Failure to rec-
Within a just culture, staff ultimately become more ognize this propagates a toxic culture that leads to
comfortable reporting errors or asking for help, as poor practice and performance, attrition, and ulti-
they know the organization supports them in their mately, a failing hospital.
efforts to improve [10, 15, 17].
Cultures that encourage and celebrate improve-
ments of all sizes and on all levels create a will- Vision
ingness amongst staff to be accountable for their
own actions as they know their work is appreci- In order for strong leaders to communicate a
ated. When leaders are openly accountable, and clear message about the vision and mission(s) of
lead by example, staff may be more willing to do the organization to staff, a hospital must first
6 Key Features in Identifying Failing Hospitals 47

ensure that a clear, overarching vision is in place. continual improvement and system enhancement
Hospitals, as complex organisms, generally have drops off, leading to a higher likelihood of poor
multiple missions under one vision [1–4]. There performance and potential failure. Diligent lead-
must be balance amongst the various mission ers who relentlessly revisit the vision of their
statements in order to fully meet the vision, as institution are more likely to see where it is suc-
this encourages collaboration amongst disparate ceeding, failing, and where optimization needs to
stakeholder groups, both internal and external, occur to engender success.
and attempts to avoid competition between these
stakeholders. Fostering collaboration over com-
petition inspires stakeholders to embrace the Information Gathering
organizational vision, and align their own indi- and Management Systems
vidual priorities with those of the hospital [10]. A
cohesive set of priorities organization-wide, sup- In order to create effective change and perform at
ported by employees at every level, strengthens the highest possible level, hospitals need to know
not only the culture of the hospital, but enhances what and how to change. This requires effective
the commitment of the entire organization to information systems and tools that allow provid-
meeting the vision. Again, this brings into focus ers to do their work, as well as collecting infor-
the need for an effective leader, a positive culture, mation that can be used by the hospital to create
and a clear organizational vision that staff and plans for improvement. Kutyla, Meyer, and
management feel aligned to. But vision is not Silow-Carroll (2004) stress the importance of
only important at the executive level. West and investing in information technologies (IT) and
Lyubovnikova (2013) discuss the importance of a tools that meet the needs of both providers and
vision at every level in the hospital, even for hospital administrators. This requires consulta-
teams on the front lines, as calling a group a tion with, and buy-in from, staff at all levels. Staff
“team” does not automatically denote successful on every level should have input as to which tools
teamwork. Teams operate best when they have a are needed to enhance their day-to-day work, and
vision in place, as well as clarity regarding the the work of the hospital as a whole, as choosing
goals and mission of the team, responsibilities of the wrong system can have disastrous effects for
the team members, and how the team should an organization, as noted by Golden (2006).
operate in order to succeed [2]. Ideally, to pro- Many organizations feel that “more is better,” but
mote excellent service provision and achieve a this is not always the case. More tools do not nec-
high level of performance, the team’s vision essarily mean better, more efficient work-flows,
would be in line with the organization’s vision and more useful information gathering. Indeed,
and mission, and reflect the values of the hospi- having too many tools available may mean that
tal’s culture. This allows for change that matches some are used, and others abandoned. In this
the goals of the organization, ultimately strength- instance, there is the chance that the wrong tools
ening the team and the hospital as a whole [14]. are used, and some excellent options discarded,
A strong, well-thought out, and widely sup- potentially to the detriment of patients, staff, and
ported vision decreases the likelihood of large-­ the organization as a whole. As such, staff need to
scale failure, so long as consideration has been be involved in every step involved in choosing
given to potential weaknesses that threaten the data systems and tools, and deciding which met-
success of the vision [9]. Anyone can write what rics to prioritize to enhance the efficacy and
sounds to be a strong, viable vision, but in health- impact of these systems [6]. In terms of informa-
care, with so many competing factors, strong tion gathering and management systems, the big-
leadership and a significant amount of thought- gest way a hospital could fail is by spending
fulness is required to achieve success. When millions of dollars or pounds on a system and set
leaders become complacent with the vision, and of tools that collect the wrong information, or
stop constantly reviewing it, the emphasis on information that is auxiliary to the needs of the
48 R. Stuhler and M. A. Koyle

hospital, and is despised by the employee base. the planning process can mitigate potential fail-
Thus the importance of careful vetting of any ure, and quash plans destined to be ineffective.
system and heavy involvement from staff at all In the case where a change has been deemed
levels cannot be underscored. necessary, leadership can foster support and
Let us assume that a hospital has succeeded in maximize the proposed change’s chance of suc-
choosing and implementing an IT system that cess by making a strong case for the initiative,
works well for staff and management. In order to allowing staff to ask questions about the plan,
ensure continued success, the hospital must focus and make suggestions that might improve the
on ongoing measurement and data analysis to process [12, 13]. Staff may be able to provide
allow for continuous improvement initiatives and suggestions that allow planned interventions to
effective streamlining of services [13]. But first be effective on multiple levels, ultimately bene-
they must determine what those measures are. fitting the hospital. Regardless of the strength of
Keroak et al (2007) discuss the importance of a proposed initiative, it is likely to fail without
using tools effectively in order to determine a set adequate increases in capacity, resources, infra-
of metrics that can be used objectively across an structure, and equipment to support the change
entire organization to make clear those initiatives [5, 13]. Leaders who do not consider the poten-
which would be most impactful to the organiza- tial weaknesses of a proposed plan, and how it
tion and ideally achieve higher performance. will affect those required to carry out and follow
Choosing the right tools keeps organizations on the plan are more likely to fail, as staff will per-
their toes, and constantly evolving. Reason ceive their commitment to the project as less
(2000) notes that the right tools remind organiza- than optimal, and will be less motivated to sup-
tions not to become too comfortable with the sta- port the intervention when implemented.
tus quo by reinforcing that constant improvement Completing a pre-­mortem and “planning to fail”
is the goal. The right system and tools are as vital by considering all potential weaknesses during
to a hospital’s success as a strong leader, positive the planning process can help leaders hone a
culture and clear vision are, as they help plot the plan and increase its chance of success [9, 23].
future direction of the organization, ideally set- Failed projects cost organizations time and
ting it up to succeed. money, and can erode employee trust and com-
mitment. This can affect the culture of an organi-
zation, and its overall performance as. Careful
Planning Processes consideration of all aspects of a change—the
cost, the required resources, and the potential
Hospitals are constantly having to change the impacts, both positive and negative, can help an
way in which they work. However, success is organization avoid complete failure of the
only achieved when change and improvement planned intervention.
initiatives are carefully thought out, planned,
and executed. One of the most common ways in
which hospitals fail is by creating initiatives Conclusion
without first considering the change needs of the
organization [21, 22]. The first potential failure It is easiest to understand why hospitals fail if we
opportunity for an organization is to propose a have a good understanding of the factors that
change that does not match the needs of the hos- allow institutions to succeed. By acknowledging
pital or local health economy, and so is perceived and understanding those factors that help hospi-
by those within the system to be a waste of time tals excel, we can more easily pinpoint the things
and money [3]. If this is the perception, there that are missing in hospitals that are underper-
will be no buy-in from staff, and less motivation forming, or failing. In order to see early those
to support or accept the change. Completing a things leading their hospitals towards failure, it is
needs assessment and involving stakeholders in essential that leaders and managers have a broad
6 Key Features in Identifying Failing Hospitals 49

understanding of the unique issues faced by hos- 11. Reason J. Human error: models and management.
BMJ. 2000;320:768–70.
pitals, and a grasp of those factors that contribute 12. Bell R, Golden B, Lee L. Transforming healthcare
to excellence, or, on the other side of the spec- organizations – looking back to see the future. Healthc
trum, suboptimal performance, and ultimately, Q. 2006;10:84–7.
failure. 13. Longenecker PD, Longenecker CO. Why hospital
improvement efforts fail: a view from the front line. J
Healthc Manag. 2014;59(2):147–57.
14. Puoane T, Cuming K, Sanders S, Ashworth A. Why
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 The Illness of the Health Care
Systems 7
Jaime Llambías-Wolff

Introduction The objective of this chapter is to explore con-

temporary contentious issues within the health
The fiscal crisis of the state paired with current field in hopes of opening and facilitating the
demographic and epidemiological transitions are debate for alternative responses. For the purpose
critically challenging health care systems. They of a more comprehensive future analysis, these
appear to be unsustainable in the face of the global critical issues have been organized into
increasing cost of care and related expenses, the four categories: (1) Epistemological Issues; (2)
significant financial impact of chronic disease, Science and Knowledge; (3) Power Relations
the over-consumption of pharmaceuticals, unaf- and the Political Economy and (4) Alternative
fordable technologies [1–4] and an increasing Approaches and Practical Implications.
demand for quality and quantity of health care.
This global crisis—affecting both the private and
the public health care systems [5–12]—has been Epistemological Issues
fully documented for no less than three decades.
Due to the limitations of this curative ideology, In relation to epistemology, several critical con-
[13–16] neither the emergence of a sophisticated tentious issues appear to be recurrent in the con-
private medical sector nor the deteriorating pub- temporary debate. Primarily, the limitations of the
lic health care system can respond effectively biomedical model appear to be one of the main
to these critical challenges as they both do not obstacles for overcoming the health crisis itself
address or challenge the hegemony of the para- [14, 21, 22]. In re-discovering and re-­visiting the
digm itself. thoughts, views and learning experiences of the
Though different schools of thought have gen- seventeenth and nineteenth centuries, there is a
erated a noteworthy body of literature, relatively renewed emphasis on focusing upon social deter-
little analysis has attempted to bridge these cri- minants, an integrated approach, the valuable
tiques. As there have been a number of alterna- input of subjective factors, the role of society and
tive paradigms put forth [7, 17–20], it is perhaps the importance of politics, economics and phi-
worth examining why suggested change within losophy in the health field.
the health field has been so slow. It appears that long after the World Health
Organization’s (WHO) declaration that health is not
merely the absence of disease, modern medicine is
still focused upon illness and infection rather than
J. Llambías-Wolff (*) structurally-based social issues surrounding health
York University, Toronto, ON, Canada
e-mail: jlwolff@yorku.ca [23]. Despite this biomedical bias, demographic

© Springer Nature Switzerland AG 2019 51

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_7
52 J. Llambías-Wolff

and epidemiological transitions—along with rising worldview” [28] ignores what lies between or
costs of medical technologies, fiscal crises of the beyond its borders [27]. Transitions toward alter-
welfare states, as well as the business approach of native health care practices and reformed public
the emerging medical-industrial-service sector— health policy currently highlight the restrictions
are forcing theorists to deconstruct the hegemonic and “inadequacies” of biomedicine, rather than
notion of the health-disease equation. As a result, alter the foundational perspectives and under-
pluralist and transdisciplinary ideologies are in standings of health and illness. There is a need
increased demand due to the overarching need for for health perspectives and health care itself to
a paradigm shift in health. become “more sensitive, critical and responsive”
It is through these failures of the biomedi- [29] to the demands of one’s physical, psycho-
cal ideology that a stigma has begun to develop logical and spiritual being. Such concepts of
against modern, biomedical, or pharmaceutically health and disease reflect how health ought to be
based treatments [24]. However, despite this cured and managed [30], yet there is currently
growing stigma and its related augmented inter- not a strong unifying alternative perspective out-
est in alternative health perspectives, there is still side the domineering biomedical ideology.
a need for biomedical treatments with respect to Using satisfaction user as indicator of suc-
the biological relationship to pathogens within cess or a need for change, the humanization of
the human body. Nevertheless, the impacts of health care is thus possible and serves as an aid
biomedicine’s historical roots are significant and for reconstructing existing health care models
undeniable. With ties deeply rooted within con- [31]. It is this humanization process [32] that
cepts of dualism, reductionism as well as the allows for a more subjective evaluation of health;
popularized “mechanical analogy” [25], biomedi- widening the definition of success regardless
cal demand is placing increased pressure on the of what respect the health care comes from. In
allocation and availability of medical resources. transitioning away from a narrow science-based
These resources—already in short supply—are legitimacy, governments are also recognizing the
found to be more tightly stretched than in previ- significance of ethics and the “social dimension
ous years, in particular due to the emergence of a of health” [33–35].
needier ageing population who tend to experience In order to promote the potential for inno-
higher rates of chronic disease and discomfort. vative views and changes, there is a need for a
Infectious diseases on the other hand are transdisciplinary “weltanschauung” (cosmovi-
becoming less of a focus for researchers com- sion). A pluralistic approach to a reconstructed
pared to previous years and instead are of more health paradigm as opposed to a “hyperdisci-
casual interest. This shift in research priority is pline” is crucial as it “proposes dialogue between
the result of an increased occurrence of antibiotic the sciences, the arts, literature [and] human
resistance [26], the emergence and re-emergence experience” [27]. First and foremost, issues of
of contagious diseases, tobacco use, sedentary complexity, logic and numerous realities must be
lifestyles, as well as malnutrition and obesity addressed [27] and not ignored. Such complexi-
across an array of both developed and developing ties pave the way for questions regarding how
nations. Health crises such as these suggest a bio- deeply entrenched the existing monolithic para-
medical incapacity and/or incapability in the face digm is to modern society as well as its potential
of more structurally based health problems that do for change.
not necessarily have direct roots in the physical
fundamentals of the biological onset of disease.
Due to the inability to effectively respond Science and Knowledge
to such issues, emerging alternative paradigms
are seen as a “movement of criticism against As Engel [21] expresses, there are a variety of
the dominant paradigm” [27] of biomedicine, limitations set out by the current scientific para-
suggesting the current “biomedical monolithic digm that allow for the development of refined
7 The Illness of the Health Care Systems 53

health care models. It is through these develop- “inform evidence-based practice, social action,
ments in research, education and health care and effective policy change” [39].
that the integration of alternative modalities, fol- Research programs are crucial in the devel-
lowed by public policy reform, has been emerg- opment of a paradigm that encompasses the
ing. According to Plack [36], the potential for a environment, biology, psychology as well as the
complete paradigm shift relies on research, as its social sciences [25]. At the same time by com-
fuelling mechanism. Plack [36] outlines how it is mitting more research to alternative methods
crucial to include the views of the researchers— and emerging paradigms in health, we are also
public policy makers, government officials, and able to determine its limitations, restrictions,
related industries—as well as those considered as well as directions for the future. Without a
stakeholders or ‘consumers’ in today’s health full understanding of the characteristics of this
market economy as part of the decision-making emerging paradigm, it is impossible to con-
process. clude that the development and incorporation
However, governments concerned with the of alternative methods would improve health
production and efficiency of health care sys- care quality and be conducive to increased
tems demand that alternative methods be evalu- accessibility. Also, medical curricula that trains
ated for legitimacy. Often, this is accomplished health professionals in biomedical and alterna-
objectively against scientific fact rather than a tive methods, for example, has been effective
more subjective or inclusive evaluative method. in developing holistic health perspectives for
Though current health research is expanding practitioners and patients alike, suggesting a
towards inter- and transdisciplinary approaches, potential break through in future developments
this must occur within all facets of health to dedicated to improving the current health crises
ensure a successful transition to invigorated from the ground up.
approaches. Though objectivity is at the founda-
tion of the development of science, we shall also
integrate the subjectivity of alternative methods,  ower Relations and the Political
P
thus offering wider standards of legitimacy as Economy
the basis upon which emerging paradigms can
prosper. Power relations and the political economy of
Alternative health paradigms are also stunted health have animated the intellectual debate for
by research capacity, as there are astounding dif- decades—many health issues themselves are
ferences in funding between biomedical versus contradictory. Although they are intertwined eco-
public health research [37]. A double standard nomically and politically, these issues relate to
exists such that complementary and alternative intangible, elusive and sometimes ethereal con-
medicine (CAM) must be “evidence-based” in cepts. They can simultaneously be the object and
order to merit research time and funding. If the the result of change, as well as the instrument of
acquisition and products of the research do not fit maintaining the status quo. Health changes need
within biomedical frameworks, related concepts to be explained with reference to the economic
of medical pluralism remain “relatively ignored” conditions and various interests they sustain,
[38]. Due to such narrow research perspectives where people are seen not as autonomous indi-
and legitimacy issues, CAM is placed at a further viduals, but as actors within specific social loca-
disadvantage with respect to its development and tions and relationships. In addition, the role of the
integration. Therefore research circles should State and the impact of economic activity cannot
promote collective and innovative perspectives be viewed as an autonomous entity in relation to
with respect to current health issues and their institutional and legal conceptual constraints. As
consequent solutions [39]. There is a need for social structure induces and influences human
a balanced incorporation of community-level activity, human activity is in turn necessary for
action in tandem with properly aimed research to its reproduction.
54 J. Llambías-Wolff

When the concept of social welfare emerged processes. Also, it shall be recognized that the
globally in 1945, most developed capitalist coun- growing so-called “middle class” is often caught
tries adopted a doctrine sustaining the Beveridge between a public sector—with enormous dif-
Report in tandem with Keynesian economic ficulties to satisfy their health care needs—and
policy. We should recall that Beveridge, while their own economic capacity to resort to private
trying to cope with the circumstances of war, medicine. This demographic has benefited from
attempted to ease the prevalent social inequal- extending private health insurances.
ity through social security and other government Despite the dominant approach, there has
subsidies. Moreover, the Keynesian theory pro- been a distinct change in health perspectives
posed to mitigate the effects of economic depres- with regards to the use, promotion and integra-
sion by acting on demand through the State. The tion of alternative health care services. Questions
implementation and further development of both arise as to whether the changing views of health
conceptualizations gave rise to what is known as and illness can be attributed to the citizens who
the Welfare State. Both right and moderate left are currently using complimentary alternative
wing political parties carried out this policy, with practices. This population perhaps consists of
its most ardent defenders being social democratic the wealthier “upper class” that are most likely
governments. to afford these less popular and consequently
Today, neo-liberal reforms have changed the generally more expensive treatments. However,
relationship between State and society [40]. this demographic is primarily made up of the
International financial institutions have played— less well-off in search of alternative healing
and continue to play—a significant role in the modalities to avoid expensive treatment plans.
formation of social policy, particularly in areas There is potential that governments could also
of health and pension programs. Social security be promoting these changing perspectives of
reforms have been promoted by World Bank health and illness in an attempt to accommo-
loans whereby the market is responsible for pro- date increased numeric and fiscal demand on
viding health and pensions. By default, the State the health care system and the burden on current
is responsible for the poor and with limited finan- services. Nevertheless, this transition towards a
cial resources this can only mean incomplete paradigm shift requires social empowerment and
access for health care [41]. According to Hart activism, inferring a population of politically
[42], there are a variety of issues on the rise with involved citizens in association with govern-
respect to the future directions for health and ments that lobby for the needs of the population
health care delivery that are currently at the mercy as an entire entity.
of industrialization and political action. Amongst
these issues lies the public versus private debate,
a struggle to determine optimal health produc- Alternatives, Approaches
tion, which has been generously publicized by and Practical Implications
popular media in recent times. Whether by a lack
of interest or the existence of alternate agendas, Through alternative and natural approaches to
the demands and desires of the population as a health, the limitations and counter productivity
whole are not being accommodated. Meanwhile, of modernization, urbanization and industrial-
those who benefit most from the current health ization are forced under the spotlight. At times,
care system, social structure and economic sys- these failures infer worsened health effects [24] as
tem continue to do so. opposed to the improved health for which they are
Nevertheless, in the current context of the lib- intended. Alternative health approaches (such as
eralization of a globalized economy and of fiscal holistic worldview, cultural synergies, traditional
inability to assume all costs of benefits, it is virtu- practices, spirituals movements, re-­ inventing
ally impossible to imagine a return to the Welfare social health, natural approaches, herbalists, natu-
State, or to dramatically reverse the privatization ral therapies, etc.) are responses to the health cri-
7 The Illness of the Health Care Systems 55

sis and intend to explore a better understanding New health paradigms must be built upon strong
of health and health determinants and develop a foundations and call for a balanced incorporation
solid and balance relationship between humans of community-based feedback as well as social
and their living physical and social environment. action, and effective policy change. Through
Some alternative theorists see health as a “pat- these processes there stands an augmented obli-
terned, emergent, unpredictable, unitary, intuitive gation for a negotiated consensus among key
and innovative view” where the human body is stakeholders in order to identify and prioritize
seen as a “dynamic field of energy” [30]. Others health targets within regional community pro-
focus on the body’s health-promoting relationship gramming frameworks [47].
with nature and its reciprocal physical and psy- Refreshingly, the new approaches do not
chological health benefits [43]. In recent times, merely focus on the managerial, funding or orga-
the emergence of a more holistic worldview of nizational aspects of health services. It is note-
health encompassing the environment, biology, worthy that alternative health movements shed
psychology, social science and other aspects, has light upon the collective and more pluralistic per-
been suggested as a reasonable dialogue between spectives of current health issues in adopting new
the sciences, philosophy, the arts, literature, ways of thinking.
human experience, etc.
This converge has begun to emerge with fore-
fronts in public health policy, patient advocacy, Conclusion
as well as the inclusion of complementary and
alternative medicine (CAM) into the existing The dominance of biomedicine is very appar-
biomedical model. Although CAM is criticized ent within current discussions regarding global
for a lack of legitimate structure in theory and health crises, creating much speculation for what
practice, the resurgence of alternative thera- must be done to yield improved health results in
pies—especially during an accelerated time of years to come. Facing resource shortages, rising
technological advancement—suggests biomedi- health care costs, heated political climates as well
cine has very clear restrictions and ‘inadequa- as economic markets spinning seemingly out of
cies’ [44]. As such, there is a growing popularity control, the health of populations is at stake such
of integrative medicine within a variety of health that the effects of these factors are now poten-
care settings and progressive health policies [28]. tially irreversible and unavoidable. In hopes of
As populations conceptualize health in differ- suggesting reformed and innovative views at
ent ways [23], there is a need to accommodate a improving and achieving health, new alternative
variety of health realities within a new paradigm, paradigms emerge as answers that are only being
parallel with the integrative skills of physicians partially explored. Due to the strict guidelines
in the changing global environment [45]. of biomedicine and scientific objectivity, these
The population involvement and the practi- alternative methods face problems of legitimacy
cal implications within the emerging paradigm and stunted development through incomplete
are also present in the field of health promo- funding and research strategies, as well as a lack
tion, as this category of social communication of political advocacy.
is also instrumental for social development [46]. Though change in perspectives, validity of
Though it has been criticized for representing an practice and political determination have begun,
economically sound escape from tackling struc- the ball is slow-rolling, in that focus still remains
tural problems by placing onus upon individuals upon expensive medical technologies and treat-
for their own health, health promotion has been ments intended to cure illness and disease rather
a mechanism for presenting broader health con- than the social determinants and an altered
cepts. Health promotion exists upon the assump- social structure. Health must be perceived as a
tion that governments are in charge of altering humanistic product whereby the mechanisms to
health perspectives and consequently, paradigms. achieve it are socially specific and accommodat-
56 J. Llambías-Wolff

ing of one’s mind, body, spirit, ethnicity, race, 12. Zola I. Culte de la santé et méfaits de la médicali-
sation. In: Bozzini, et al., Médecine et Société: les
gender and social and economic circumstances. Années 80, op. cit. 1981.
To accomplish this feat, inclusive and inter- and 13. Bozzini L, Renaud M, Gaucher D, Llambías-Wolff
trans-disciplinary approaches must be adapted J. Médicine et Société-les Années 80. Québec:
by emerging health paradigms and the conse- Éditions Coopératives Albert Saint-Martin; 1981.
14. Capra F. The biomedical model. In: The turning
quent health care system, in hopes of meeting point: science, society, and the rising culture. London:
the surmounting health crises and providing sus- Fontanta; 1982.
tainability in health for the future. Whether the 15. Lupton D. The Lay Perspective on Illness and Disease.
industrialization and commodification of health In: Medicine as culture: illness, disease and the body
in western societies. London: Sage; 1994.
is irreversible or not, we must make a valiant 16. Turner A. Concepts of Disease and Sickness:
effort to understand and dissect the mechanisms Women’s Complaints: Patriarchy and Illness. In:
and structures underpinning the current circum- Medical power and social knowledge. London: Sage;
stance in order to move forward with new, inno- 1987.
17. Gordon, J. Conversations: James Gordon, MD, con-
vative and revisited ideas. necting mind, body and beyond. In: Alternative thera-
pies in health & medicine, March/April. 2006.
18. Gordon J. Asian spiritual traditions and their useful-
ness to practioners and patients facing life and death.
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 The Political Economy of Health
Reforms in Chile: A Case Study 8
of the Privatization Process

Jaime Llambías-Wolff

Introduction the political actors and the organized civil soci-

ety, as well as the armed forces. Governments
Health issues are contradictory. Although they have bargained with labor factions, urban work-
are intertwined economically and politically, they ers, employees, the police and the armed forces
relate to intangible, elusive and sometimes ethe- separately, ultimately resulting in a very hetero-
real concepts. They can simultaneously be the geneous structure, where the rights and benefits
object and the result of change, and the instru- of these factions have come to depend on the
ment of status-quo. Health reforms need to be negotiation power of the stakeholders Murdock
explained with reference to the economic condi- [1] and [2].
tions and the various interests they sustain, where This chapter discusses the evolution of the
people are seen not as autonomous individu- Chilean health care system along with the result
als but as actors within specific social locations of negotiations that transpired between a web of
and relationships. Therefore, the question: “who economic, political and cultural forces during
benefits?” is essential to uncover the process of the following time periods where crucial health
health reforms. reforms were implemented.
An analysis of the way power is employed
to influence policies, reforms and legislation
remains sometimes neglected or underestimated. Theoretical Concerns
How has Chilean socio-economic and political
development influenced and shaped the different Changes to the health care system must be con-
health models and reforms? How was hegemony sidered in light of the broader social, economic
built into the process of implementing health and political factors. According to Frenk, a Health
reforms? What were the ideological, economic System can be understood as “a set of relation-
and socio-political factors behind these health ships among major groups of actors: the health
reforms? care providers, the population, the State as a col-
The context of health reforms in Latin America lective mediator, the organizations that generate
and in Chile was more the articulation of conflict- resources, and the other sectors that produce
ing interests in the political arena, mediated by services with health effects” [3, p. 19]. From a
the political strength and mobilization capacity of comparative perspective all countries have similar
concerns, but the economic, political, ideological
and epidemiological reasons behind them differ.
J. Llambías-Wolff (*) Social reforms have also an ambiguous character.
York University, Toronto, ON, Canada
e-mail: jlwolff@yorku.ca In the process of deepening social reforms we are

© Springer Nature Switzerland AG 2019 59

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_8
60 J. Llambías-Wolff

confronted with a plurality of objectives that cor- a non-mechanistic interpretation of the processes
respond to different interests. This process has also of creating law and of the confrontation of inter-
a paradoxical, but probably necessary dialectical ests, negotiation and the dynamic role of ideol-
nature: it facilitates equity, promotes protection ogy. Neo-Gramscian analysis views hegemony as
and democratizes society, while also legitimizing a terrain of struggle where social prevalent ideas
the State and a system of power that has created must be constantly articulated and rearticulated
its own inequality and lack of protection. at the various levels of the social structure Gill
As indicated by Fitzpatrick in relation to the [8], Rupert [9] and Augelli and Murphy [10]. The
development of the Welfare State: “since a wel- concept of hegemony is essentially a concept that
fare democracy would require a more egalitarian expresses a form of domination, which is exer-
distribution of power and resources as exists at cised in different ways and also originates in
present, we need an account of those from whom lawful ways, but it is invariably linked to power
power and resources would need to be redistrib- relations and the power structure in a society. For
uted” [4, p. 12]. The Welfare State has improved this reason, it is important to examine how the
income distribution, but has also influenced and State acts and reacts in this process, where hege-
affected the accumulation of capital. On the other mony is exercised.
hand, it has also induced changes in labour pro- The role of the State is critical, since it “acts
ductivity, but deepened as well many of the values as strategic terrain for the implementation of
and rights that workers have acquired over time. hegemonic projects” and it is the site of major
In addition, the role of the State and the impact struggles as well as negotiations, compromises,
of economic activity cannot be viewed as an consent, articulations, inclusions and exclusions
autonomous entity in relation to institutional and [11, p. 183]. This is similarly noted by Barton
legal conceptual constraints. Social structures when he states that, “theories of social contract,
induce and influence social and human activ- of hegemony and of class struggle all refer to
ity, but social activity is also necessary for the these changing social relations and how the State
reproduction of the social structure. Therefore, is then co-opted by different social groups for dif-
within a larger political context the need is to ferent ends” [12, p. 361].
secure conditions for this reproduction and the Conflict among stakeholders to intervene in
constructing of hegemony. Poulantzas argues the process of health policies and the delivery
that classes and social groups have many differ- of health care services is a constant struggle.
ent determinations, which consequently require a Influence and capability of mobilizing interest
negotiation of interests through a block that “con- groups on health reforms have historically been
stitutes a contradictory unity of politically domi- important in several Latin American countries.
nant classes and fractions, under the protection This is particularly interesting, since Health
of the hegemonic fraction” [5, p. 239]. Systems in Latin America are characterized
For Gramsci, who anticipated much of the as being fragmented systems [13, p. 170; 14,
work done by the structuralists, neo-marxist, pp. 162–116]. It is difficult to classify them as
structural-marxists like Althusser [6] and later purely public or private, due to the complex
by poststructuralists and post-modernists: “The arrangements and negotiations that are the result
hegemonic process is then defined not simply on of political choices Heidenheimer et al. [15].
the basis of the relations between groups, but on Systems of social protection, differing in each
the basis of the relations between groups and country, have been formed through diverse his-
structures” [7, p. 178]. By conceptualizing that torical development. These social protection
the super-structure may have autonomy with systems are developed through a combination of
respect to the infrastructure, and bearing in mind economic, political and cultural forces. These
that orthodox historical materialism did not con- forces, along with unique sets of social val-
sider this in the same terms, the Gramscian inter- ues shared by the population, form a complex
pretation left the door open to the possibility of web of institutions “responsible for financing,
8 The Political Economy of Health Reforms in Chile: A Case Study of the Privatization Process 61

organizing and providing social service deliv- and of a negotiation process between actors and
ery”, which define “who is entitled to benefits interests at play [18, p. 75]. It is particularly
and services” [16, p. 1]. interesting to note that the active participation of
Countries in Latin America were left with interest groups—in their various expressions—in
a very stratified health care system; workers in national health reforms, began at the opening of
the formal labor market were entitled to social the twentieth century, before the Welfare State.
security benefits, while the rest of the popula- When the concept of social welfare emerged
tion received services provided by the State, in the world in the 1945s, most developed capi-
consequently creating differences and inequities talist countries adopted the doctrine sustaining
amongst sectors. Latin America has developed its the Beveridge Report along with Keynesian eco-
own system of social protection originating in pro- nomic policy. We should recall that Beveridge,
found economic, political, and cultural changes while trying to cope with the circumstances of
that accompanied the process of industrialization war, attempted to ease social inequality through
and urbanization. The role of the State became social security and other government subsidies.
more interventionist in order to ensure emerging Moreover, the Keynesian theory proposed to
social rights [16, p. 1]. Also, as earlier discussed, mitigate the effects of economic depression by
the system was also determined by the dynamics acting on demand through the State. The imple-
of a power struggle between the important classes mentation and further development of both con-
and social actors, and the ability to mobilize their ceptualizations gave rise to what we know as the
goals and forge alliances to create temporary Welfare State. Both right and moderate left wing
social consensus [16, 17, pp. 2014–2015]. political parties carried out this policy, with its
Consequently, it is the implementation of a most ardent defenders being the social demo-
policy originating from above (the State) that cratic governments.
generated a period of unprecedented economic In addition, the Welfare System encouraged
growth, ensuring a standard of living, pro- market and production, promoted peace, social
viding employment and basic social services stability and social consensus. The Welfare State
(health, education, retirement), for the people of has not only improved the distribution of income
the countries that adopted such a pathway. For and affected the accumulation of capital, but has
Fleury, “The concept of social protection in Latin also induced changes in labour productivity, and
America rested on social and institutional mech- the values and rights that were gained during an
anisms of differentiation. Nevertheless, this polit- individual’s lifetime. Although what we define
ical give-and take constituted the first instance today as a Welfare State stems from different
in which the demands of the working class were conceptions, both philosophical and moral in
considered in the political arena and incorpo- their social historical genesis, the role and posi-
rated in the government agenda” (…) Social pro- tion of the State has been unquestioned in the
tection was rooted in a political system wherein epicentre of the social, economic and political
the State played a key role in the industrialization process [19, 20].
process by combining industrial protectionism Policy and legislation changes are the out-
with a controlled political incorporation of urban come of a negotiation process where forces
workers’ demands” [16, pp. 2–3]. and interests of the actors are confronted [21].
The legitimacy of the State was built under The process of articulation, adaptation, re-­
a corporatist approach, following the European articulation, and resistance for health reforms
model. In England and Wales the Health System can only be understood as valid in an economic
was built with an active participation of the work- and political context. It is particularly interesting
ing class, creating a hierarchical system with the to note that although the organized civil society
provision of services according to levels of care. and political parties usually promote changes,
The consolidation of a national Health System the State can also be involved in the negotiating
was achieved thanks to several political contexts process to articulate and frame changes.
62 J. Llambías-Wolff

 hilean Health Reforms

C in ensuring social rights, subjecting the right of
and Negotiation Through History ownership to what was considered the “rule of
social progress”, protecting labor and industry
The Development and enforcing legal protection for workers and
of the Welfare State social welfare. It also proclaimed that Public
Health Service was a duty of the State. The most
The Chilean State’s efforts in the health field important of these social laws was the creation of
began in 1890 with the creation of an agency in the Workers Insurance Fund, which later became
charge of public hygiene and sanitation, but the known as Social Security Service (SSS).
modernization of public institutions begun in Later by 1938, the Popular Front Government,
the late second and third decade of the twentieth (Pedro Aguirre Cerda) favorable to demo-
Century, with President Arturo Alessandri Palma. cratic socialist ideas, implemented the Law of
During his first and second mandate Chile pro- Preventive Medicine which allowed the screen-
mulgated a new constitution, a new Labor Code, ing of all blue and white collars workers for
Tax Law, Sanitary Law and Social Security Law, contagious and chronic diseases. In 1939, Dr.
all in anticipation of several aspects to global Salvador Allende, Minister of Health (who
trends having its origins in the treaty of Versailles became President in 1970), wrote a book that fur-
and the International Labor Organization. The thered Virchow’s research as he advocated that
government, in pursuit of the Bismarkain exam- social rather than medical solutions were neces-
ple, provided health services to workers and sary in order to combat current health problems.
their families, [22, pp. 156–157] and the State The Chilean Socio-Medical Reality, “conceptual-
assumed an active role with universal health care ized illness as a disturbance of the individual fos-
and the consolidation of State responsibility in tered by deprived social conditions” [24, p. 75]
public health. Social security was extended for a and focused on specific health problems that
program that favored the employees of Railways were generated by the poor living conditions of
and the mid-20s witnessed the creation of orga- the working class: maternal and infant mortality,
nizations like the National Public Employees tuberculosis and sexually transmitted diseases.
(CANAEMPU) and the Fund for Private At that time these suggestions were considered
Employees (EMPART). not only innovative but also definitively revolu-
The year 1924 (military intervention) also tionary. In 1940, the Popular Front Government
marked another stage in the history of social leg- presented a project in which it clearly appeared
islation in Chile, because it was from this date that a more comprehensive form of coverage was
that the first social laws began to be enacted. needed to reduce health care inequities and cen-
They were, however, welcomed by employ- tralize the management of all hospitals under a
ers, workers and doctors [23]. The health leg- single government agency.
islation and reform that followed reforms were The period between 1917 and 1939, patented
not intended to reduce the activities of private the State responsibility in matters of health and
assistance, but to consolidate a centralized body welfare. However, the multiplicity of institutions
for social and health policies. The creation of that were created resulted in costly health care ser-
the Workers’ Compulsory Insurance, or Social vice. An integrationist and centralized movement
Security, in 1924 became the central piece in the began to develop a new alternative reform at the
history of public health in Chile. These events end of the 30s, which reached its peak in 1952,
suddenly transformed the medical profession into as a process that was developed through negotia-
a privileged intervener in the construction of the tions between governments, unions, health work-
State and radically changed the morphology of ers and the medical profession, each representing
its labor market [23]. Finally the new constitution its own political, economic and corporate inter-
(1925) reflected the global trends by increasing ests [25]. The outcome was the establishment, in
individual rights and the obligation of the State 1952, of the National Health Service (Servicio
8 The Political Economy of Health Reforms in Chile: A Case Study of the Privatization Process 63

Nacional de Salud—SNS), which was the major structure of the National Health Service (SNS)
health provider in Chile for four decades. Like [17, 27]. The government also implemented
in Western Europe, full employment provided the reforms to increase public involvement in health
ideological cement for hegemonic order through- care, to control the pharmaceutical industry, to
out social democracy. In the case of Chile, the encourage citizen participation in health care
Welfare State provided the legal framework for management, and to achieve health care equity by
social and health reforms, inclusive of labor pro- creating a Unified National Health Care Service.
tection, social stability and a more Keynesian Hoping to resolve gaps in health benefits,
state involvement in economic development. the government of the Unidad Popular aimed to
Later in the 1960’s, in response to pressure restructure health services, streamline medical
from the growing middle class, the government care, increase access, and coordinate activities;
took the initiative to develop a new program for and in turn, frame them within a dynamic and
white-collar employees (SERMENA). It permit- effective national plan. This task was entrusted
ted users to select their physicians, stimulated a to a Single Health Service (Servicio Unico de
semi-public insurance system and created pri- Salud). The new organizational structure was
mary and preventive care clinics and laboratories called to incorporate public institutions and to also
for the middle class that were no longer fully cov- absorb health institutions responsible for provid-
ered by the public system. In this case the social ing health care services to the different segments
sphere represented the “harmony ideology”, of the middle class. These institutions, however,
preaching the discourse of “public interest” in under the umbrella of the medical system for
order to maximize social welfare. Reforms were employees (SERMENA), created during the
the culmination of an incremental process, rather Christian Democracy government (1964–1970),
than a rupture with the past, where the govern- alienated an important sector of the population.
ment was the dominant group and able to dictate This applies to the understanding that the
reform policy over the objections of opposing victory of the Unidad Popular in Chile in 1970
interest groups in civil society [22, pp. 156–157]. cannot be considered a historical accident, but
As analyzed by Fleury, “the social; policies rather, the result of a crisis in the historic bloc
that have developed in most Latin American along with the strengthening of organized popu-
countries are rooted in a similar development lar movement. This major policy change resulted
model. They are responsible for some of the most in a radicalization of the social figure of health
significant features of the relationship between and materialized with the completion of several
the State and society, as well for the incorpo- transformations in this sector: a more visible
ration of a particular power structure into an presence of State control of the national phar-
institutionalized system” [16, p. 1]. This pattern maceutical industry, foreign participation in the
of structured social interactions express sev- field of management and the democratization of
eral characteristics, such as stratification and or access to services, which would lead to a unified
exclusion of certain population groups, fragmen- national service. It was implemented through a
tation of institutions, a narrow and fragile finan- health policy that ensured decisive participation
cial basis and strong actors with vested interests of the population and the transformation of the
represented in the political arena [16, p. 1]. ­organizational structure of the National Health
Health reforms were clearly “process-oriented”, Service, through centralization in decision-mak-
including the organizational structure in order to ing and decentralization of implementation.
reorganize relations between public and private Although the revolutionary rhetoric was firm
sectors, managers, policymakers, providers and in place, in practical terms, these reforms did not
consumers [26, p. 1]. represent a paradigm shift or a model change. They
Between 1970 and 1973, the Unidad Popular were more a change in the management of services
(Popular United) government introduced reforms and in the consolidation of the public sector as the
to democratize and centralize the organizational spinal column and nervous center of the Chilean
64 J. Llambías-Wolff

Health System. It was the ultimate expression and approach, transferring important responsibili-
willingness to continue with a more popular and ties to the private sector, curtailing benefits and
democratic management of health services. The reducing State involvement in funding of pub-
sum of social transformations, especially the eco- lic policies and their administration [32, p. 37].
nomic transformation undertaken by the govern- The new approaches adapted the liberal theses of
ment of the Unidad Popular proved however to economists like Rostow, Misses and Hayek and
be a significant menace for large domestic and modify them to suit the final decades of the twen-
foreign economic interests. tieth century. In Chile, this materialized in the
The hegemonic shifts within the actors them- decisive influence of the “Chicago boys” based
selves and the role played by the State, was mod- in the University of Chicago, and particularly
ifying the correlation of forces in the historical that of Milton Friedman and Harold Harberger.
hegemonic bloc (see [28]). If the rule of law is However, the state overstepped its original legal
seen as an ideology that legitimizes and conceals frameworks, as it intervened arbitrarily in the
power relations [29, pp. 5–14], it is interesting economy, breaking the rules of economic free-
to see how in the case of Chile, the rule of law dom, as it was privately criticized on several
was also instrumental for changing power rela- occasions by the same Milton Friedman.
tions. Thus it became clear that the other forms The neoliberal Chicago School was opposed
of power relations, like force, had to take place to to governmental economic intervention, reject-
reestablish bloc hegemony. ing market regulations and Keynesianism and
It is at this point that the breakdown of democ- adopting monetarism, except for interventions to
racy appeared as a precondition for the restoration save the market and the banks (like in the Chilean
of the factors that would allow the reinstatement financial crisis in the 1980s,1 which put the new
of the liberal economic model, earlier threatened economic model in peril). The influence of this
by economic changes undertaken during the gov- neoliberal school within the Chilean government
ernment of the Unidad Popular. In the field of and the particular role played by the “Chicago
health, the change was drastic. It altered one of boys”, as well as the policies of the International
the keys to Chilean social history, as the process Monetary Fund and the World Bank, were deci-
of building the road to institutional reform in sive in bringing about this shift in the economic
Chile (which began in the 1920s) was character- model. The new model imposed a new logic,
ized by the legal incorporation of the working and social consciousness around health issues
classes into the State. became neutralized, making health concerns an
The military Coup of 1973 and the restructur- individual problem and stimulating the atomiza-
ing of the State, which passed to play a subsidiary tion of society and the promotion of health care
role, ensured the free exercise of market activi- as business.
ties and a health market model characteristic of As already discussed, until 1973, Chile was a
neo-­liberal models. Incremental health reforms pioneer in Latin America in terms of social pol-
were disrupted by the military regime, where icy, developing one of the most universalistic sys-
the implementation of a new health model, alter- tems on the continent. The new health model was
ing the previous reforms and plans, challenged altered in three significant areas: first, in terms of
the Welfare State and opened the way for a neo-­ the social spending program that affected out-of-­
liberal market model [30, 31]. pocket spending by patient; second, by the enroll-
ment of the middle and upper-middle class in

 he End of the Welfare State

T
and a New Market Model 1
The crisis in Chile that began in 1981 and lasted until
1986 saw inflation rise to almost 30% and caused a cur-
rency devaluation of 40%, which created a serious debt
The military dictatorship (1973–1989) replaced problem, exacerbated by a significant drop in the price of
the public-oriented system with a market-­oriented copper, the principal source of foreign exchange.
8 The Political Economy of Health Reforms in Chile: A Case Study of the Privatization Process 65

private pre-paid health institutions (ISAPRES)2 Service.7 According to Decree-­Law 2763, health
and third, through the transfer of public health service agencies were functionally de-central-
clinics to county (municipalities) management, to ized, with independent legal capacities and their
reduce State bureaucracy and State-financed care own resources for fulfilling their duties. They
[33, p. 68]. These changes minimized the State’s were charged with the implementation of inte-
responsibilities and stimulated the development grated development, protection and restoration
of private health care, health insurance and the of health and the rehabilitation of sick people.
growth of the pharmaceutical industry. This in Policy-making power was transferred from the
turn, was a logical step for incorporating health SNS back to the Ministry of Health, and the exec-
into a liberal economic framework [34–42]. utive power to implement curative and preventive
Four basic aspects of the public health care services was decentralized in the new National
system—policy, service provision, financial man- Health Services System.
agement and primary care—were reorganized. Thirteen regions and twenty-seven semi-­
Decree-Law 27633 (August 1979) re-­organized autonomous local health systems were created
the Ministry of Health and created the National across the country, which finally became the
Health Service System,4 the National Health legal successors of the National Health Service
Fund,5 the Public Health Institute of Chile6 and and the National Health Service for Employees
the Central Supply Centre of the National Health (SERMENA). The health service agencies, the
National Health Fund, the National Council for
2
Institutos de Salud Previsional, ISAPRES, created by Food and Nutrition, the Public Health Institute
Law 18,933 (1990) which also derogated DFL no 3 of Chile, the Central Supply and the National
(1981). Health Service were also brought under the ambit
3
Decree Law 2763 (1979). Regulations for the Ministry of of the Ministry of Health8. The partial withdrawal
Health, National Health Service System, National Health
Fund, Public Health Institute of Chile and Central Supply of the state from curative services and the limi-
Centre of the National Health Service. In addition, it tations suffered by the public sector in general
established the foundations for a de-regionalized National constituted a loss of decades of progress and
Health Care System. It established a Ministerial Health experience.
Secretariat for each of the country’s regions and created
Health Services authorized to delegate tasks to the univer- Social policy was guided by market-oriented
sities, unions, employers’ associations and other bodies principles, including the reduction of state inter-
with technical capacities for the activities assigned to the vention, the strengthening of the private sector,
Health Services. The funding would come from the the adoption of free-market and stabilization pol-
National Health Fund, which was the legal successor to
SERMENA and the SNS. icies and the privatization of public corporations
4
Each Service was under the charge of a director, respon-
sible for the supervision, coordination, and control of the 7
The Supply Center of the National Health Service came
facilities and services of the system. into being as a functionally de-centralized public service,
5
The National Health Fund was a functionally de-central- again, with a legal capacity and financial resources of its
ized public service, with a legal capacity and financial own. It provided the medicines, instruments and other
resources of its own. Legally, it was a continuation of the supplies that may be required by the agencies, organiza-
National Health Service for Employees and the National tions, institutions and persons affiliated to the Health
Health Service, for the purpose of carrying out adminis- System, for the implementation of incentive measures,
trative and financial actions. protection or restoration of health, and the rehabilitation
6
The Public Health Institute of Chile was created as a of sick people. The Supply Central was the legal successor
functionally de-centralized public service, also with a of the National Health Service.
legal capacity and financial resources of its own. It con- 8
The Ministry of Health was responsible for formulating
tributed to the national laboratory, and was a referential and implementing the health policies. It had to perform
source for s the fields of Microbiology, Immunology, the following functions: direct and guide all government
Pharmacology, Clinical Laboratory, Environmental activities relating to the health system; lay out the internal
Pollution and Occupational Health. It was the legal con- technical, administrative and financial regulations to be
tinuation of the National Health Service with respect to its followed by the agencies, and institutions of the health
relation with the Bacteriological Institute of Chile and the system; and supervise, monitor and evaluate the imple-
National Institute of Occupational Health. mentation of policies and health plans.
66 J. Llambías-Wolff

and state companies and industries. Social policy the capacity to pay and the accessibility of ser-
had to be consistent with economic rationality vices [46, pp. 31–32]. Additional factors taken
[32, p. 55]. Promoting private medicine and mak- into consideration by patients included the subse-
ing it profitable necessarily implied extending its quent cost of follow-up treatments and drugs10 as
market potential by increasing the consumption well as the loss of income during recovery. Given
of private medical services. The disbursement of these constraints, which were not insignificant,
financial resources in the public health system increasing the capacity of patients and users to
was redirected from subsidizing the supply of pay became one of the financial challenges of
health care services to subsidizing the demand the new liberal health care model. This situation
for such services. The previous system of direct was further exacerbated when the principles of
budget allocations distributed by the SNS was cooperation and coordination between differ-
swapped with production criteria [43, p. 384]. ent services and institutions were replaced with
Thus, the direct allocation of public funds to inter-institutional competition. There was also
health care institutions via an annual budget was a tendency to reorganize the availability of ser-
reduced in order to increase the allocation of vices to target the most profitable types of medi-
funds as reimbursement for actual services ren- cal specializations.
dered, creating competition between institutions. The goal was to facilitate the transfer of
Until the sanction of Decree-Law 2575 in 1979, savings to private insurance institutions, thus
only 16% of the budget was allocated according increasing the users’ capacity to choose services
to production criteria and 63.7% by direct budget and simultaneously stimulating the private prac-
allocation, with another 20% coming from direct tice of medicine and the development of private
income and donations [44]. Decree-Law 25759 clinics and, eventually, hospitals. The new mar-
(1979) extended the benefits of Law 16,781 to ket approach was clearly reflected in the type
the beneficiaries of the National Health Service. and variety of services offered, which now had to
This policy of subsidizing demand even fur- incorporate time as a variable to maximize profit.
ther weakened the capacity and the image of the Furthermore, artificial demand was created with
entire public sector and stimulated the growth the introduction of more screening appointments,
and legitimization of the private sector. Need-­ excess consumption of non-essential medical ser-
based access to services was replaced with access vices and the promotion of greater drug use, all
based on an individual’s capacity to pay prices
that depended on real demand as determined in 10
In developed countries, drug expenses represented
a market economy, [45, p. 394] in which health between 9% and 10% of the budget destined for health
care was just another commodity. The “demand” services. These figures more than doubled in underdevel-
oped countries. These numbers were even more eloquent
for health care was not actually the result of an in Chile, as it was reported that pharmaceutical expenses
individual’s decision to use medical services comprised of almost a third of all expenses recorded in the
based on his or her medical needs; rather, it health sector. Ernesto Medina & Ana María, Kaempfer,
was the result of several other factors, such as “Análisis crítico de la metodología de planificación de
salud”, (1968) Revista Médica de Chile 455. The concen-
tration of the pharmaceutical industry in Chile demon-
9
Decree-Law 2575 extended the medical and dental ben- strated that in 1977, out of 57 active companies, 24 were
efits of Law 16,781 (1968) to the beneficiaries of the foreign and the 5 largest of these already controlled 32%
National Health Service. The legal beneficiaries of the of the market. The leading 25 companies controlled
National Health Service were eligible for the health care 80.5% of the total market and 18 were foreign multina-
system under Law 16,781, without prejudice to the care tionals. Also, since foreign pharmaceutical companies
that they were entitled to of that service in accordance hold patents rights the possibility of transfer of technolo-
with Law 10,383 and its amendments. The National gies was very limited. At the same time, this allowed arti-
Health Service had to pay the amount equal to the percent- ficially high pricing, sales linked to the purchase of other
age paid by the Medical Assistance Fund, as established products and finally restrictions in domestic exportation.
by Law 16,781. Any difference between the amount See Constantine Vaitsos in Meredeth Turshen, “An analy-
funded by the National Health Service and the total value sis of the medical supply industries”, (1976) 6
of the benefit was charged to the beneficiary. International Journal of Health Services at 275.
8 The Political Economy of Health Reforms in Chile: A Case Study of the Privatization Process 67

part of, as described by the regime, a sophisti- of the state, as individual and personal relations
cated approach to medical care. with curative services would be strengthened. To
The privatization process was based on a very privatize social security and to alter the respon-
clear economic rationale of stating why and how sibility of the state in the services sector meant
to impose and implement the new liberal market to transform “social concern” into an “individual
model in the health sector, which, as indicated concern”. This change was also politically inter-
above, included an articulated process to reduce esting given the traditional strength of the health
the public sector, stimulate the growth of the sector as a force of organization and popular
private sector and lastly, expand the market for cohesion.
the private sector. This was precisely in line with It is, in effect, with respect to health issues
neoliberal political and economic principles, that people may develop a “social conscious-
according to which private sector interests and ness” about the problems that afflict individuals.
market laws become the impulse for develop- This consciousness allows them to share simi-
ment. In summary, these political-economic poli- lar claims and channel forms of social struggle.
cies in the health field were no guarantee of better Castells and Clarke [51, 52, p. 102] defines these
health care; rather, they were tools to increase the processes of politicization as a “socialization of
profitability of the “business” of medicine and claims” where collective consciousness focuses
the medical-industrial complex. on collective action. In contrast, the neutraliza-
These clearly neo-liberal reforms changed the tion of claims and the atomization of society stem
relationship between State and society, either by precisely from the individualization of interests,
replacing political logic with market principles when health issues become individual problems
or by creating new forms of control and partici- and not social concerns. This particular scenario
pation [47, pp. 27–28]. International financial also echoed the global health care crisis, char-
institutions have played, and continue to play a acterized by fiscal limitations for the expansion
significant role in the formation of social pol- of socialized medicine in increasingly expensive
icy, particularly in areas of health and pension health care scenarios. In the face of the increasing
programs. Social security reforms have been cost of care and the significant financial impacts
promoted by the World Bank loans under a neo- of chronic diseases that accompany an aging pop-
liberal framework, in which the market becomes ulation, the high demand for pharmaceuticals and
responsible for providing health and pensions. more demanding specialized technology, reforms
The neo-liberal reforms were able to start the and potential solutions focused mainly on organi-
dismantling of the Welfare State, where the State zational and financial measures to contain costs,
became only responsible for the poor. However improve efficiency and transfer the responsibil-
with limited financial resources this can only ity to patients. The crisis of modern, specialized
mean limited access and care [48]. medicine, accelerated by demographic and epi-
Although these reforms were presented as an demiological transitions, was also revealing how
appropriate strategy for the rationalization and the patient was becoming the target to blame in
modernization of the health care system (as it was the health-illness process [53, p. 663] and the
believed to improve efficiency and effectiveness, source of revenue in the health care business.
while reducing cost and bureaucracy), they were As discussed the military regime established
criticized for both their inequities and their priori- a new legal framework that redefined the pub-
tization of market expansion [31, 42, 49, 50]. lic system, creating open competition between
We must look to the history of Chilean soci- medical establishments. According to promot-
ety and its profound inequalities to understand ers of the model, this new “healthy and effec-
why the majority of the population was unable to tive competition in health care services” was a
exercise this “freedom option”. The government correction to the state’s ineffectiveness as a pro-
initially believed that the real freedom of individ- vider of medical services and a solution for the
uals would be guaranteed by the subsidiary role “financial anarchy” of distributing resources and
68 J. Llambías-Wolff

establishing costs [54]. They reiterated that the politically influential within a framework of elec-
reform process not only imposed regulations on toral democracy [12, p. 372].
the public sector to improve its effectiveness, but One of the major consequences of the chang-
also brought renewed economic dynamism to the ing role of the State in health policy has been the
management of curative services, which would blurring of the respective roles, responsibilities
result in “increased income for health profession- and jurisdictions of the public and private spheres
als”, “more new sources of employment”, “a new [56]. Today, in Chile, the health services system
incentive to the investment-deprived sector” and can be labeled as a “mixed system”, through its
“reduced health costs” [55]. combinational financing and service provision.
However, despite the government’s principles In the current context of liberalization of a glo-
and objectives, transformations in the health sec- balized economy and of fiscal inability to assume
tor were not easy to implement and did not take all costs of benefits, it is virtually impossible to
place as quickly as expected. Although support- imagine a return to the Welfare State, or to dra-
ers of the model continued to try to implement matically reverse the privatization processes.
a broad, market-driven approach, others within Also, it shall be recognized that the growing,
the same military regime were more cautious so called, middle class, often caught between a
and preferred to keep the state as the principal public sector with enormous difficulties to sat-
actor responsible for the health sector. The inter- isfy their health care needs along with their own
nal dissent and conflicts between health profes- economic capacity to resort to private medi-
sionals slowed down the Ministry’s action plans cine, have benefited from the extending private
and brought modifications to the proposed health health insurances. Consecutive Chilean govern-
model. The public sector had historically been ments under the administration of the center-left
considered to play a fundamental role in health political coalitions (first the Concertación por
care, with a role too critically important to be la Democracia and later the Nueva Mayoría),
suddenly modified. Thus, the government was elected and reelected in five elections, following
forced to continuously defend itself from its crit- the end of the dictatorship, have made progres-
ics, indicating that it did not want to implement sive but not radical changes in health policies.
“either a cold market model or a state model”. Its These governments maintained the foundations
polemical pragmatic discourse favoured a com- of the model, but progressively implemented
bination of market policies and policies based reforms to expand coverage, improve the public
on the responsibility of the state. The regime system, and allow for major investments in health
labelled it a “social market economy”, probably infrastructure, which illustrates that health poli-
following the liberal German model. The idea cies and reforms are not only the outcome of eco-
was that the private sector and the market would nomic and political change, but also the result of
invigorate social development, while the subsid- negotiations between different players.
iary role of the state would protect fundamental
social interests.
After the years of dictatorship and when the Conclusion
Pinochet regime was later replaced by the demo-
cratic Aylwin government in 1989, the country The State apparatus has always had enormous
saw an establishment of new changes and reforms; importance in the structure and administration of
particularly a renewal of State intervention and Chilean society and has even assumed a leading
implication in the Health field. Rather than a role since the second half of the twentieth cen-
complete withdrawal from previous reforms, this tury. The State has penetrated corners of public
however was accomplished progressively [22, and private social life, becoming the most impor-
p. 165; 12, p. 372], since the hegemonic bloc that tant agent of production and reproduction of
had its roots in the authoritarian period was still society.
8 The Political Economy of Health Reforms in Chile: A Case Study of the Privatization Process 69

An adequate study of the whole cannot be 4. Fitzpatrick T. In search of a welfare democracy. Soc
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 Part V
The Turnaround Process
 The Role of Medical Leadership
in the Hospital Turnaround Process 9
Prasad Godbole and Derek Burke

Introduction experience in management to run highly complex

organisations and could be biased by their clini-
Who Are Medical Leaders? cal views in terms of hospital innovation and
transformation. Others argue that doctors prefer
Historically non-clinical managers managed hos- to be led by doctors and the role of the medical
pitals with clinicians providing front line services manager acts as a conduit between the hospital
[1]. Over the decades, more and more clinicians board and the shop floor. A third view suggests
have taken on managerial responsibility and in that where medical managers continue to provide
many instances giving up their clinical duties to direct clinical care to patients, they will tend to
take on full time management roles. In the US a prioritise their clinical responsibilities rather than
recent survey has shown that up to 51% of man- their managerial responsibilities thereby putting
agers in hospitals are doctors [2]. undue additional pressure on their management
In countries such as India, hospitals may be as colleagues, often at critical times such as the win-
small as 5–10 beds and owned and managed by ter period.
doctors in their entirety. Larger corporate hospi- Whatever the arguments for and against medi-
tals with up to 2000 beds are managed jointly by cal managers, it is clear that greater numbers of
doctors and non-clinical managers. A systematic doctors are venturing into management roles but
review has shown some evidence to suggest that at the same time retaining at least some of their
where doctors work in a hybrid role as clinicians clinical responsibilities. Increasingly doctors are
and managers, the performance of the hospital is gaining qualifications in medical leadership and
better than for hospitals having only non-clinical healthcare management thereby increasing their
managers [3]. Such findings often give rise to understanding of the management process. The
heated debate and can lead to polarised views. gaining of such qualifications addresses some of
Many people argue that doctors in managerial the perceived experiential gap between profes-
roles may not have the necessary expertise or sional non-clinical managers and emerging clini-
cian managers.
P. Godbole (*)
Department of Paediatric Surgery, Sheffield
Children’s NHS Foundation Trust, Sheffield, UK Wider Context
e-mail: Prasad.Godbole@sch.nhs.uk
D. Burke For any hospital to succeed, the hospital as a
Department of Emergency Medicine, Sheffield whole must have a vision that the entire organisa-
Children’s NHS Foundation Trust, Sheffield, UK
e-mail: Derek.Burke@sch.nhs.uk tional staff signs up to. To achieve this corporate

© Springer Nature Switzerland AG 2019 73

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_9
74 P. Godbole and D. Burke

Level 1
CORPORATE
VISION

Level 2 Divisions/SBUs
MARKET FINANCIAL

Level 3 CUSTOMER Business operating

FLEXIBILITY PRODUCTIVITY
SATISFACTION systems

Level 4 Departments
QUALITY DELIVERY CYCLE TIME WASTE

External effectiveness Internal efficiency

Fig. 9.1 Project management triangle. Source Lynch and Measurement%20Practices%20and%20Operational%20

Cross 1989 (http://erepository.uonbi.ac.ke/bitstream/han- Performance%20of%20Manufacturing%20Firms%20
dle/11295/100103/Kamau_Performance%20 in%20Kenya.pdf?sequence=1&isAllowed=y)

vision, the management team must understand less revenue with less money to be spent on
the cost of providing the services and how the cleanliness of the hospital or quality improve-
vision can be delivered within the organisational ment programs. In the US, this has led to some
cost ceiling. Customer (patient) satisfaction must hospitals having their Joint Committee
be monitored and minimum productivity stan- Accreditation revoked or Medicaid/Medisure
dards agreed with the flexibility to increase pro- contracts terminated. In the U.K. the National
ductivity as necessary. Finally with productivity Health Service Hospitals are monitored across a
comes the quality of service delivery and out- number of patient focused domains for the qual-
comes and the minimising of waste. The above ity of care (Care Quality Commission)1 and
project management triangle (Fig. 9.1) can be financial viability also scrutinised by
simplified for healthcare organisations as shown MONITOR2—a governmental regulatory body.
below:
For any hospital to function requires a speci-
fied operating budget for the day to day opera-  ow Can Medical Leaders Assist
H
tions of the hospital including staff salaries, in the Turnaround Process?
equipment, procurement, maintenance etc. The
performance of the hospital is the activities the As already discussed previously, more and more
hospital undertakes to generate income. This pro- doctors are leaning towards management roles in
ductivity in turn has to be balanced by the quality an executive capacity. In the U.K. there is a hier-
of outcomes, patient experience and patient archical organisational management structure
safety. With increasing constraints on healthcare with medical representation at executive board
resource allocation may it be in insured/private level. A generic outline of the management
markets or those free at the point of delivery,
management teams must maintain the delicate www.cqc.org.uk.
1

balance between the three factors. Where perfor- https://improvement.nhs.uk/resources/?publishingbody=

2

mance and productivity reduces, this generates monitor.

9 The Role of Medical Leadership in the Hospital Turnaround Process 75

Fig. 9.2 The inverted Chairman and Non Executive Board of Directors
pyramid
CEO
COO Dir of finance Dir of HR. medical Dir. Dir of Nursing Dir IT

Divisional managers

Departmental managers

Middle management team

Doctors, nurses, allied healthcare workers, non clinical staff

s­ tructure is shown below As can be seen from the a balanced budget and at the same time meet
above, there is a tendency for a top down approach targets
with the ‘doers’ at the bottom of the pyramid and 3. Experience: ensuring patients are receiving
the decision makers at the top- an inverted pyra- good quality, safe care
mid (Fig. 9.2).
We use the term quality here to meet deliver-
ing to standard, e.g. if the standard is one quali-
Background fied nurse to every four patients then delivering
that level of cover meets the criteria for achieving
The medical director approaches a transforma- the quality standard for nursing levels. Falling
tional change process in a hospital with trepida- below this level means that the quality standard
tion. The hospital will be under significant has not been met. If the standard is evidence
scrutiny and may have external consultants based then failure to meet that standard is likely
directing the day to day activity and expenditure to increase the risk to patient safety.
of the hospital. The medical director will be Finance, Delivery and Experience are inter-­
under considerable pressure to contribute to the related. Hospitals need to deliver sufficient activ-
delivery of financial savings but should be clear ity to generate income to remain in financial
about their prime professional responsibility balance and meet targets to avoid financial diffi-
which is to ensure that patients are safe. Before culties or even regulatory penalties. Hospitals
describing an approach to this task we need to require sufficient income to recruit and retain
understand the strategic landscape in which hos- staff to deliver activity and maintain a safe, high
pitals operate and the inter-relationship between quality service. Hospitals have to achieve all
cost, quality, safety and risk. three at the same time.
Organisations run into problems when there is
undue focus on one strategic objective to the det-
Strategic Objectives of Hospitals riment of the other two: commonly a dispropor-
tionate focus on financial stability at the expense
In addition to any internal strategic objectives all of delivery and experience. Because of the inter-­
hospitals have three common strategic relationship between cost, quality and safety a
objectives: failure to balance the three strategic objectives
will inevitably results in compromised patient
1. Finance: staying within budget safety.
2. Delivery: delivering a volume of activity suf- As the diagram below (Fig. 9.3) indicates it is
ficient to generate sufficient income to ensure the function of the Hospital Senior Management
76 P. Godbole and D. Burke

Fig. 9.3 Inter-­relationship between finance

cost, quality, safety and risk

delivery experience
activity targets quality safety
expenditure governance risk management
efficiency
effectiveness
expansion
extension

Fig. 9.4 Interrelationship between

cost, quality and safety
safety
qu
a
lity

cost

Team to ensure that the three objectives are given care to agreed standards (Quality) to ensure that
equitable consideration. patients are kept form harm (Safe). The following
Hospitals spend money in order to deliver graph (Fig. 9.4) provides a qualitative representa-
high quality activity safely. Ensuring there is suf- tion of the inter-relationship.
ficient staffing of the right level of experience and A minimum level of expenditure is required to
skill mix to deliver services is the major item of deliver a given level of safety. For each level of
expenditure for most hospitals (~75% of the aver- expenditure there is a range of levels of safety
age hospital expenditure in the UK). Money which can be realised depending on the decisions
(Cost) is expended to deliver specified aspects of on what money is spent on. The wrong decision
9 The Role of Medical Leadership in the Hospital Turnaround Process 77

on what to spend money will realise a lower level cial measures or have significant restrictions by
of safety for a given expenditure than is the regulators. But note that judicious decision
possible. making by an organisation with lower expendi-
We can describe the three dimension surface ture due to financial constraints can still be asso-
(Fig. 9.5) which the cost/quality/safety matrix ciated with a safe environment.
maps out as the patient safety landscape. High Note that this landscape illustrates a qualita-
levels of expenditure generally result in a safe tive model for the relationship between cost/qual-
environment in which the organisation is regu- ity and safety. We can add a quantitative element
lated but at arm’s length (as long as the metrics by mapping out the hospital’s incident risk scores
used to assess the organisation’s safety profile are onto the landscape. This is illustrated below for a
maintained). A low level of expenditure is more hospital which is low risk (Fig. 9.6). The validity
likely to result in a less safe environment: in of this mapping is predicted on a good reporting
extreme cases the hospital may be put into spe- culture which can be assessed by the position of

Fig. 9.5 Patient safety landscape as a

three dimension surface regu
late
d

safe
ty la
nds
cap
e

spe
cial
mea
sure
s

Fig. 9.6 Mapping of incident scores

of a low risk hospital on patient safety
landscape Low

mo
der
ate

hig
h

ext
reme
78 P. Godbole and D. Burke

the organisation on the reporting metric chart for underlying problems. Overall this will lead to a
example on the National Reporting and Learning longer time required to bring the organisation
System site for Hospitals in England.3 back into a sustainable position.
When running the diagnostic three parallel
tracks should be pursued:
 he Medical Director in a Failing
T A review of the papers of the last three
Hospital Undergoing Hospital board, board committees and corporate
Transformation management team meetings will give an insight
into the managerial function of the organisation
The medical director must be able to differentiate from the management perspective.
between the important priorities and the urgent Walking the floor to speak with the frontline
priorities. Urgent patient safety issues will need staff who delivers the service is crucial. They
to be addressed as they arise. The important pri- will inform the medical director of the front line
orities are less time dependant but there will be staff’s perspective of the management culture
pressure to prioritise them as they will usually and its impact on the quality and safety within
relate to primary finance issues (cutting costs) or the organisation. Staff will usually be aware of
secondary finance issues (ensuring income is the key operational issues which need
secured through the maintenance of activity addressing.
levels). The patient’s perspective can be assessed by
In addressing the important problems the speaking with patients who are currently using
medical director should allow themselves suffi- the service and by reviewing complaints, Serious
cient time to run a thorough diagnostic on the Incident Root Cause Analyses and patient sur-
hospital. In the best of times this process can take veys (in-patient, out-patient and the emergency
upwards of 3 months (ask any medical director department).
how long it took them to gain an understanding of Needless to say the staff and patients will give
the issues in their new job and they will rarely the medical director the best insight into the
come up with a figure of less than 3 months). For effectiveness of the management team. Trends in
a hospital in turnaround the same timescale the staff survey should form a key part of this
should be adhered to. Failure to undertake an review.
accurate diagnostic analysis will have similar The review of the minutes of the committees,
consequences to arriving at the wrong diagnosis staff and patient perspective will usually provide
in a patient: at best time wasted pursuing solu- sufficient information for the medical director to
tions which will not work; at worse causing harm ascertain the core problems within the hospital
to patients. and to formulate solutions.
The medical director will be pressurised to The next stage is to develop a strategy to
find solutions to the problem with the risk that address the problems. The early wins will be
they will generate solutions without clearly iden- achieved by addressing workforce health and
tifying the underlying problems: identifying the wellbeing issues and reviewing the organisa-
root cause of the failure is a pre-requisite to com- tion’s values set and how well they have been
ing up with solutions. It is often the case that implemented. A rapid assessment of whether the
when the true problems have been identified the information being acted on is based on accurate
correct solutions present themselves. and timely data collection, submission and anal-
Do not be rushed into arriving at pre-emptive ysis is essential. As quantitative finance data and
solutions until you are sure you are aware of the information is usually easy to collate there is a
risk that this will be prioritised; do not under-
3
https://improvement.nhs.uk/resources/learning- estimate the value and power of qualitative
from-patient-safety-incidents/. data and information. Staff and patients views,
9 The Role of Medical Leadership in the Hospital Turnaround Process 79

properly triangulated will provide earlier warn- References

ings of patient safety going off track than the
quantitative data provided in board reports. 1. Spehar I, Frich JC, Kjekshus LE. Clinicians in man-
agement: a qualitative study of managers’ use of influ-
The early diagnostic phase is likely to take up ence strategies in hospitals. BMC Health Serv Res.
to 3 months: it can be achieved in less but time 2014;14:251.
will inevitably be taken up in managing urgent 2. Clay-Williams R, Ludlow K, Testa L, Li Z,
operational issues which are directly threatening Braithwaite J. Medical leadership, a systematic nar-
rative review: do hospitals and healthcare organisa-
patient safety. This diagnostic will generally sug- tions perform better when led by doctors? BMJ Open.
gest the strategy to be followed, the priority to be 2017;7(9):e014474.
assigned to the individual components of the 3. Sarto F, Veronesi G. Clinical leadership and hospi-
strategy and a realistic timescale for the individ- tal performance: assessing the evidence base. BMC
Health Serv Res. 2016;16(Suppl 2):169.
ual actions.
 Public Health Service Governance:
Principles and Framework 10
Erwin Loh and Katherine Lorenz

About This Chapter the future of a public entity are taken, com-
municated, monitored and assessed.
This chapter sets out a proposed public health
service’s governance framework and describes Governance in the public sector is built
the systems in place to ensure that the health ser- on:
vice Board, Executive and all staff of the organ-
isation are accountable for the clinical, corporate, • constitutional, legal and government
financial and operational aspects of the frameworks;
organisation. • government decision making and
reporting;
• authorisations and delegations in
decision-making;
Good Governance Provides the Foundation
• accountability, transparency, integrity,
for High Performance
stewardship, efficiency and leadership;
Good governance strengthens community
• values and codes of conduct;
confidence in public entities and helps
• effective risk management;
ensure their reputations are maintained
• the integrity bodies—protecting public
and enhanced. It should enable public enti-
entities against crime and misconduct.
ties to perform efficiently and effectively
and to respond strategically to changing
A board with decision-making powers is
demands.
formed to govern a public entity.
Governance encompasses the processes
Governance gives practical meaning to
by which public entities are directed, con-
public sector accountability obligations.
trolled and held to account. It includes the
For such public entities, governance defines
processes whereby decisions important to
the relationships between the board, senior
management, the minister, portfolio depart-
ment, stakeholders and integrity bodies.
Victorian Public Sector Commissioner1

E. Loh (*) ∙ K. Lorenz

Monash Centre for Health Research
and Implementation, Monash University,
Clayton, VIC, Australia 1
https://vpsc.vic.gov.au/governance/governance-structure-
e-mail: erwin.loh@monash.edu; ceo@vicbar.com.au and-roles/governance-structure/.

© Springer Nature Switzerland AG 2019 81

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_10
82 E. Loh and K. Lorenz

Case Study The result of this is an almost immediate

improvement in staff morale and culture as there
The public health service in question is one of the were now clearly lines of accountability and
largest public health services in Australia, which reporting, with a concomitant improvement in
provided healthcare to one quarter of this state’s financial outcomes, procurement practices and
population, across the entire life-span from new-­ overall better clinical, operational and budget
born and children, to adults, the elderly, their performance. The case study shows the impor-
families and carers. The health service has more tance of starting with the foundation of the prin-
than 17,000 staff work at over 40 care locations, ciples of good, robust governance, and how that
including six hospital campuses, and an exten- forms the basis of effective health service provi-
sive network of rehabilitation, aged care, com- sion that leads to great patient care and an excel-
munity health and mental health facilities. lent staff and patient experience.
Each year, the health service provided more This chapter provides a template for other
than 3.6 million episodes of care to its commu- public health services who may wish to embark
nity, with more than 260,000 people admitted to on a similar journey of developing their own gov-
its hospitals, more than 220,000 receiving care at ernance framework and includes a check-list that
its emergency departments, performing more may be helpful as part of that process.
than 48,000 surgical procedures, and delivering
more than 10,000 babies.
Health Service Clinical Governance
The health service for many years did not have
a consolidated governance framework that was
Clinical Governance is a systematic and inte-
clearly articulated in a single document located
grated approach to assurance and review of clini-
centrally that was easily accessible to its staff,
cal responsibility and accountability that
patients and the community. As a result, there
improves quality and safety and patient out-
was confusion as to the role of the health service
comes.2 Clinical Governance is linked to corpo-
Board, its Executive team, the senior managers
rate governance, strategic risk and service
and the frontline staff. This led to a confused del-
planning, informatics, performance and business
egation of authority leading to unclear lines of
management. The Health Service Clinical
accountability, a lack of discipline around finan-
Governance Framework is the system by which
cial management, poor procurement practices,
the Board, Executive, clinicians and staff share
uncoordinated and unrestricted staff appoint-
responsibility and accountability for the safety
ments, and disjointed reporting lines, which
and quality of care. Clinicians and clinical teams
resulted in an adverse budget outcome due to
are responsible and accountable for the quality of
uncontrolled costs, uncapped staff increases and
care provided. The Board and Executive are
lack of contract management, as well as low staff
responsible and accountable for ensuring the sys-
morale from reactive actions taken by middle
tems, structures and processes are in place to sup-
managers to attempt to compensate for the poor
port clinicians in providing safe, high quality
governance.
care and for clinician engagement in improve-
A review occurred with the appointment of
ment and risk management activities.
new executives, including a new Chief Legal
Compliance of clinical governance is mea-
Officer, which led to a systematic review and the
sured through accreditation mechanisms and
development of a new governance framework
through the health service Quality Committee
from the ground-up, which included clear delin-
eation of roles and responsibilities of all levels of
management and staff, that are evidence-based, 2
https://www.safetyandquality.gov.au/wp-content/
compliant with legislation and accessible to all uploads/2017/11/National-Model-Clinical-Governance-
employees. Framework.pdf.
10 Public Health Service Governance: Principles and Framework 83

which provides leadership and advice to the Board management requirements set out in the relevant
through the continuous assessment and evaluation mandatory risk management regimes.
of the safety and quality of clinical services pro- This includes (inter alia) ensuring that health
vided by health service. service:

(a) has an Enterprise Risk Management

 orporate and Financial
C Framework developed in accordance with ISO
Governance 31000:2009 Risk management—Principles
and guidelines3; and
The Board needs to meet a range of requirements (b) arranges all its insurance with the relevant
under the relevant financial legislation; including medical indemnity insurance authority.
keeping proper financial accounts, risk manage-
ment, audit arrangements, financial reporting,
annual reporting to Parliament and responding to Other Legal Obligations
Ministerial requests for information.
To comply with the obligations in the relevant The Board ensures that the health service com-
financial legislation, the public health service plies with all relevant legislation, including:
must ensure that, inter alia:
• Legislation relating to financial management
• The CEO has designated a suitably qualified and reporting obligations.
employee as the CFO. • Legislation relating to the administration of
• The CEO and CFO have systems in place to employee and patient information.
keep proper accounts and financial records • Legislation relating to accountability and
generally, a system for promptly preparing transparency requirements.
and auditing the annual financial statements, • Legislation relating to the safety and rights of
an assets register, and a system for the timely mental health patients, such as the complaints.
preparation of its annual report. • Legislation to improve the safety and protect
• The CEO and CFO have effective systems in the rights of employees.
place to receive, record, implement and moni-
tor directions issued by the relevant Minister. The Board receives reporting on legislative
• An audit committee is in place. compliance on an annual basis via the Audit
• The audit committee has approved an internal Committee.
audit charter.
• The risk management program includes a
financial risk management program. Health Service Board
• The finance delegations meet the requirements
of legislation. The role and duties of the health service Board
• The CEO and CFO have systems in place to include strategy, governance and risk
receive and respond promptly to requests for management.
financial and other information from the rele- The health service Board sets the strategic
vant Minister. direction of the health service and monitors that
health service is meeting its objectives and per-
formance targets outlined in its Strategic Plan.
Risk Management and Compliance The health service Board has established this
governance framework and monitors compliance
The health service Board must ensure that the
health service also complies with mandatory risk 3
https://www.iso.org/standard/43170.html.
84 E. Loh and K. Lorenz

with the framework. This framework covers the –– effective and accountable risk management
clinical work of the organisation, as well as the systems are in place;
corporate and financial aspects of its operation. –– effective and accountable systems are in
The Board also ensures that risk management place to monitor and improve the quality
is integrated into health service’s systems and and effectiveness of health services pro-
reviews the effectiveness of operational risk man- vided by health service;
agement, compliance and reporting systems. –– any problems identified with the quality or
effectiveness of the health services pro-
vided are addressed in a timely manner;
Board Functions –– health service continuously strives to
improve the quality of the health services it
The Board must perform its functions and exercise provides and to foster innovation;
its powers subject to any lawful direction given by • Board sub-committees are established and
the Minister and in accordance with the provisions operate effectively;
of the relevant legislation. Additionally, the Board • appoint a chief executive officer of health
is responsible for the oversight of the implementa- service and to determine, subject to the gov-
tion of government policy and guidelines issued ernment approval, his or her remuneration
from time to time from the Department of Health and the terms and conditions of
and other government agencies. appointment;
In brief, the role of the Board is to provide • monitor the performance of the chief execu-
strategic direction for health service and effective tive officer of health service, each financial
oversight of management. year, having regard to the objectives, priorities
The functions of the Board are to: and key performance;
• establish the organisational structure, includ-
• develop statements of priorities and strategic ing the management structure, of health
plans for the operation of health service and to service;
monitor compliance with those statements and • develop arrangements with other relevant
plans; agencies and service providers to enable effec-
• develop financial and business plans, strategies tive and efficient service delivery and continu-
and budgets to ensure the accountable and effi- ity of care;
cient provision of health services by the public • ensure that the relevant Minister and bureau-
health service and the long term financial via- crat are advised about significant board deci-
bility of the public health service; sions and are informed in a timely manner of
• establish and maintain effective systems to any issues of public concern or risks that affect
ensure that the health services provided meet or may affect health service;
the needs of the communities served by health • establish a Finance Committee, an Audit
service and that the views of users and provid- Committee and a Quality Committee;
ers of health services are taken into account; • facilitate health research and education;
• monitor the performance of health service to • adopt a code of conduct for staff of health
ensure that: service;
–– health service operates within its budget; • provide appropriate training for directors;
–– its audit and accounting systems accurately • any other functions conferred on the board by
reflect the financial position and viability or under the relevant legislation;
of health service; • each year ensure that the Chief Executive
–– health service adheres to its financial and Officer convenes an annual meeting during
business plans, strategic plans and state- which the Board submits the report of opera-
ments of priorities; tions and financial statements;
10 Public Health Service Governance: Principles and Framework 85

• appoint at least one community advisory com- • attend, at a minimum, 75% of Board meetings
mittee and ensure that the persons appointed and any committee meeting they may be
to the community advisory committee are per- involved in during the year.
sons who are able to represent the views of the
communities served by health service;
• appoint a primary care and population health Board Chair
advisory committee and ensure that the per-
sons appointed to the committee have the One of the directors must be appointed according
knowledge and expertise; to the relevant legislation to be the chairperson of
• include in its report of operations, a report on the Board.
the activities of its advisory committees. The position of Board chair is important
because she or he is the major point of contact
between the Chief Executive Officer and the
Board Obligations Board, leads the Board and develops its members
as an effective team. The chair has a particular
Pursuant to its obligations set out in the relevant role to play in relation to effective Board opera-
legislation, in performing its functions and tion. This includes effective, efficient and con-
­exercising its powers, the health service Board structive chairing of meetings and managing the
must have regard to: evaluation of the CEO and Board. The Board
chair is responsible for ensuring a Board evalua-
• the needs and views of patients and other users tion, chair and individual director evaluations
of the health services that health service pro- occur annually with an externally facilitated
vides and the community that health service review at least every 3 years.
serves;
• the need to ensure that health service uses its
resources in an effective and efficient manner; Board Selection
and
• the need to ensure that resources of the public Board composition is important for board effec-
health sector generally are used effectively tiveness. Appointments to the Board are usually
and efficiently. made in consultation with the Board Chair. To
maximise the Board’s capacity for effective gov-
Board Membership ernance the right mix of skills, expertise and per-
sonal attributes are required. It is also important
The composition of the health services Board is to achieve a balance between new members and
usually set out in the relevant legislation. ideas and corporate memory. The Board Chair
The Board should include at least one person and Directors, through the Board self-evaluation
who is able to reflect the perspectives of users of process, determine a view on the most effective
health service and that women and men are ade- composition for the Board, including skills mix
quately represented. and gaps, and provide advice on this to the
It is an expectation that Board members (inter Minister, if required.
alia):

• undertake identified and agreed training and  oard Member Resignation

B
development in order to fully discharge their and Removal
responsibilities;
• bring to the attention of the Board chair any A director of the Board may resign in writing,
actual or perceived conflict of interest or signed by that person, and the appropriate body or
potential conflict of interest; individual as outlined in the relevant legislation
86 E. Loh and K. Lorenz

may remove a director from office, if it is satisfied Audit Committee

that the person: The Audit Committee is a Committee of the
Board. The purpose of the Audit Committee is to
• is physically or mentally unable to fulfil the assist health service and its Board by providing
role of director; or assurance in the key areas of statutory financial
• has been convicted of an offence, the com- statements, internal control, legislative compli-
mission of which, in the opinion of the ance and oversight of the activities of risk man-
Minister, makes the person unsuitable to be a agement, internal and external audit.
director; or The role of the Audit Committee is as
• has been absent, without leave of the Board follows:
of directors, from all meetings of the Board
of directors held during a period of 6 (a) independently review and assess the effec-
months; or tiveness of the health service’s systems and
• is an insolvent under administration. controls for financial management, perfor-
mance and sustainability, including risk
management;
Board Committees (b) oversee the internal audit function, including
to:
The Board delegates some aspects of its work to 1. review and approve the internal audit
its committees. The committees are able to carry charter;
out a more detailed analysis of certain issues and 2. review and approve the strategic internal
make recommendations for the Board to con- audit plan;
sider. The Board remains accountable for all 3. review and approve the annual audit work
decisions. program;
Health service’s Board committees are each 4. review the effectiveness and efficiency of
established with: the function;
5. advise the agency on the appointment
• clear terms of reference; and performance of the internal auditors;
• procedures for agendas, minutes and reporting and
to the Board; and 6. meet privately with internal auditors if
• appropriate membership. necessary;
(c) review annual financial statements and make
On discharging their obligations, all commit- a recommendation to the health service
tee members will ensure they take into consider- Board as to whether to authorise the
ation the health, safety and welfare of persons at statements;
health service in all decision making, including (d) review information in the report of opera-
the promotion of a zero harm culture within the tions on financial management, performance
health service. and sustainability;
The Health service should establish the fol- (e) review and monitor compliance with the rel-
lowing committees: evant financial legislation, and advise the
health service Board on the level of compli-
• Audit Committee ance attained;
• Quality Committee (f) review and monitor remedial actions taken to
• Remuneration Committee address compliance deficiencies;
• Finance Committee (g) maintain effective communication with
• Consumer Advisory Committee external auditors, including by:
• Primary Care and Population Health Advisory 1. understanding the external audit strategy
Committee and internal audit activities;
10 Public Health Service Governance: Principles and Framework 87

2. considering the external auditor’s views clinical governance of quality and safety at health
on any issues, including accounting issues service. It serves to ensure on behalf of the Board
that may impact on the financial state- of Directors of health service, that the following
ments, financial management compliance broad objectives are fulfilled:
issues and other relevant risks impacting
the health service’s finances; • Effective and accountable systems are in place
3. considering external audit outcomes, to monitor and improve the quality and effec-
including financial and performance tiveness of all health services provided by
audits; health service.
4. providing a standing invitation to the • Any problems identified with the quality or
external auditor to attend Audit Committee effectiveness of the health services provided
meetings; and are addressed in a timely manner.
5. meeting privately at least once each year • The health service continuously strives to
to ensure frank and open communication; improve the quality of all the health services it
(h) consider recommendations made by inter- provides and to foster innovation.
nal and external auditors relating to or
impacting on financial management, perfor- Remuneration Committee
mance and sustainability and the actions to The principal role of the health service
be taken by the health service to resolve Remuneration Committee is to advise the Board
issues raised; and of Directors on matters relating to the organisa-
(i) regularly review implementation of actions tion’s remuneration policies and practices.
in response to internal or external audits, In addition, the health service Remuneration
including remedial actions to mitigate future Committee will provide oversight with respect to
instances of non-compliance. succession planning for the Chief Executive and
senior executive positions.
The Audit Committee must be independent Within the parameters established by the
with: Board, the Remuneration Committee is respon-
sible for:
(j) at least three members who are non-­
executive directors of the health service • Developing and reviewing the organisation’s
Board; executive remuneration policy and practices
(k) an independent member as Chair (this must and ensuring that the strategies and perfor-
not be the Chair of the Board); mance of health service are taken into
(l) self-assess its performance annually and account.
report this assessment to the health service • Advising the Board on “best practice” trends
Board; and and practices in employment conditions and
(m) not include the following persons as employee remuneration, including the chang-
members: ing legal requirements on executive and senior
(n) the Chief Executive; management remuneration.
(o) Chief Financial Officer; or • Recommending remuneration movements for
(p) the internal auditors. the Chief Executive to the Board and for
approving remuneration movements for senior
Quality Committee executives and senior managers.
The Quality Committee is a Committee of the
Board of Directors. The purpose of the Quality Finance Committee
Committee is to support the Board’s function of The Finance Committee is a Committee of the
providing strategic leadership in relation to the Board of Directors. The purpose of the Finance
88 E. Loh and K. Lorenz

Committee is to advise the Board of Directors on • Balance sheet position; and

financial matters impacting health service and to • Fundraising activities.
establish and maintain effective financial gover- • Other matters specifically delegated to it by
nance, including: the Board.

(a) an appropriate internal management struc-  ommunity Advisory Committee

C
ture and oversight arrangements for plan- The Community Advisory Committee is an advi-
ning, managing and overseeing the financial sory committee established by the Board of
operations, risks and opportunities of their Directors. The Board must ensure that:
health service to achieve performance and
compliance;
(a) persons appointed to the Community
(b) appropriate levels of resourcing and capabil-
Advisory Committee are persons who are
ity (including succession planning) to deliver
able to represent the view of the communities
health service’s financial management, per-
served by health service and
formance and sustainability obligations;
(b) In appointing persons to the Community
(c) clear roles, responsibilities, accountabilities
Advisory Committee, preference is given to
and delegations that are documented and
a person who is not a registered health prac-
communicated;
titioner, nor a person who is not currently or
(d) the development and implementation of poli-
not recently been employed or engaged in the
cies and procedures to support the internal
provision of health services.
control system, in a way that is consistent
with, and appropriate for, the sound financial
management of health service’s business The role of the Community Advisory
operations; Committee is to:
(e) the effective management and oversight of
health service’s financial management activi- • Identify and advise the health service Board
ties that are undertaken externally, including of Directors on priority areas and issues
shared services arrangements and outsourc- requiring a consumer, carer and/or commu-
ing to private sector providers; nity perspective.
(f) effective relationships between stakeholders, • Advocate on behalf of consumers, carers and
committees of the Board and management; the community, including promoting greater
(g) cooperation with external parties, including attention and sensitivity to the needs of
other Agencies, to achieve common objec- diverse, disadvantaged, isolated and margin-
tives; and alised consumers and communities.
(h) consideration of the effect of compliance • Provide direction on the development of a
burdens when developing and imposing strategic Community Participation Plan for
requirements. approval by the health service Board of
Directors and monitor its implementation and
Specifically, the Finance Committee will effectiveness, including overseeing the prepa-
review, monitor and report on the following: ration of an annual report to the Department of
Health on progress against the Community
• Financial strategy and direction; Participation Plan.
• Financial performance and reporting; • Provide direction and advice on the imple-
• Financial risks; mentation of the accreditation standards rele-
• Capital planning, major projects, major ten- vant to consumers and patient experience, and
ders and business cases; monitor implementation and evaluation across
• Investments and cash flow; health service.
10 Public Health Service Governance: Principles and Framework 89

• Participate in the health service strategic plan- Directors’ Ethical and Legal
ning process and provide ongoing monitoring Obligations
and input into the strategic priorities.
• Facilitate two-way communication between Code of Conduct
consumer, carer and community groups and
health service. The public health service directors’ are subject to
• Participate in monitoring Quality and Safety the Directors’ code of conduct. The code of
measurements and Patient Centred Care key conduct expresses the public sector values in
performance indicators for quality terms that are most relevant to the special role
improvement. and duties of Directors. The Directors’ code of
• Assist in identifying development and training conduct is based on the same set of values (the
needs in relation to consumer, carer and public sector values) that apply to all public offi-
community participation and make recom-
­ cials, including employees.
mendation to the health service Board of A health service director must:
Directors on how to meet these needs.
• Act with honesty and integrity. Be open and
In undertaking these responsibilities, the transparent in their dealings; use power
Community Advisory Committee can seek infor- responsibly; not place oneself in a position of
mation and briefings on health service core activ- conflict of interest; strive to earn and sustain
ities and programs. public trust of a high level.
• Act in good faith in the best interests of
Board Effectiveness and Evaluation health service. Demonstrate accountability
for their actions; accept responsibility for
The Board evaluates its own performance annu- their decisions; not engage in activities that
ally, and undertakes an externally facilitated may bring themselves or health service into
review at least every 3 years in order to identify disrepute.
areas of improvement and to provide develop- • Act fairly and impartially. Avoid bias, dis-
ment for the Directors’ and the Board. crimination, caprice or self-interest; demon-
The Board Committees review their perfor- strate respect for others by acting in a
mance annually and provide recommendations to professional and courteous manner.
the Board of any actions that should be taken to • Use information appropriately. Ensure infor-
improve the Committee’s performance. Each mation gained as a director is only applied to
Board Committee reviews its Charter annually. proper purposes and is kept confidential.
• Use their position appropriately. Not use their
position as a director to seek an undue advan-
 elegations to the Health
D tage for oneself, family members or associ-
Service Executive ates, or to cause detriment to health service;
decline gifts or favours that may cast doubt on
The Board has delegated powers to the CEO and their ability to apply independent judgment as
Executive. The delegations of authority provide a a health service Board member.
list of functions that have been delegated by the • Act in a financially responsible manner.
Board. The delegation manual includes a descrip- Understand financial reports, audit reports and
tion of the delegated power and any conditions other financial material that comes before the
limiting the exercise of those powers (including health service Board; actively inquire into this
financial limits). material.
The delegations are reviewed annually by the • Exercise due care, diligence and skill.
Finance Committee and approved by the Board. Ascertain all relevant information; make
90 E. Loh and K. Lorenz

reasonable enquiries; understand the financial,  ealth Service’s Executive

H
strategic and other implications of decisions. Committee
• Comply with the establishing legislation for
the health service. The health service’s Executive Committee is
• Demonstrate leadership and stewardship. responsible for the day to day running of health
Promote and support the application of the service, in accordance with the law, the decisions
Victorian public sector values; act in accor- of the Board and government policies.
dance with the Directors’ Code.

Chief Executive Officer

Conflicts of Interest
The Board appoints the Chief Executive Officer
The Directors’ code of conduct requires Directors
(CEO) of health service and determines, subject
to act with honesty and integrity and to act in the
to the Secretary’s approval, the CEO’s remunera-
best interests of health service. This means avoid-
tion and the terms and conditions of his or her
ing placing themselves in a position of conflict of
appointment.
interest. Obligations in relation to conflicts of
The CEO is subject to the direction of the
interests are further articulated in the health ser-
Board in controlling and managing health ser-
vice’s Conflict of Interest Policies.
vice. The functions of the CEO are:

Duties of Directors • to prepare material for consideration by the

Board, including the Strategic Plan;
Health service Directors must act honestly, in • to ensure that health service uses its resources
good faith in the best interests of health service, effectively and efficiently;
with integrity, in a financially responsible man- • to implement service development and plan-
ner, with a reasonable degree of care, diligence ning; and
and skill, and in compliance with relevant • any other functions as specified by the Board.
legislation.
Health service Directors must not give to any The role of the CEO is to:
other person, directly or indirectly, any informa-
tion acquired through being a director (apart from • manage the effective and efficient operations
when carrying out functions authorised, permit- of health service in accordance with the strat-
ted or required under an Act). egy, business plans and policies of the Board;
Health service Directors must not improperly • implement Board decisions;
use his or her position, or any information • ensure health service’s organisational func-
acquired through that position, to gain a personal tions are effective, including financial man-
advantage, or for the advantage of another per- agement, human resource management, asset
son, or to cause detriment to health service. management and reporting;
• maintain effective communication and co-­
operation with stakeholders in collaboration
Declaration of Private Interests with the Chair of the Board;
• oversee the employment and management of
Health service Directors’ are required to com- staff;
plete an updated Declaration of Private Interests • provide advice and information to the Board
on an annual basis. Any perceived or actual con- on any material issues concerning strategy,
flict of interest which is declared by a director is finance, reporting obligations and significant
to be managed in accordance with the health ser- events that require the Board to notify the
vice Conflict of Interest Policy. Minister and Department of Health;
10 Public Health Service Governance: Principles and Framework 91

• prepare health service’s Annual Report; • the internal control systems to avoid fraud and
• liaise with the Department of Health; and misappropriation;
• represent health service to external parties as • liaison with external auditors;
an official spokesperson for health service, in • the audit process;
consultation with the Chair of the Board. • action taken on audit reports; and
• managing financial risk.
The CEO is usually the accountable officer for
health service the relevant legislation. As the
accountable officer, the CEO must:
External Regulatory and Monitoring
• designate an employee as the CFO, and desig-
nate other staff who receive money and make The health service is subject to regulation and
payments; oversight from a number of external bodies.
• ensure that proper accounts and records are
kept;
• provide the Minister for Health or the Minister The Government
for Finance any financial information they
request; The Department of Health and government agen-
• prepare financial statements and report of cies have a number of key clinical governance
operations; responsibilities including:
• complete the annual Financial Management
Compliance Framework as soon as possible • setting expectations and requirements regard-
after the end of each financial year; ing health service accountability for quality
• write off debts, losses or deficiency in health and safety and continuous improvement;
service accounts in accordance with the regu- • ensuring health services have the necessary
lations; and data to fulfil their responsibilities, including
• organise investigations into the loss, defi- benchmarked and trend data;
ciency or destruction of public money or prop- • providing leadership, support and direction to
erty that may have been caused by a serving or ensure safe, high-quality healthcare can be
former office of health service and decides provided;
whether to try to recover funds from that • ensuring board members have the required
officer. skills and knowledge to fulfil their
responsibilities;
• proactively identifying and responding deci-
Chief Financial Officer (CFO) sively to emerging clinical quality and safety
trends;
The CFO is responsible for health service’s finan- • effectively monitoring the implementation
cial accounting and financial reporting, the effec- and performance of clinical governance
tiveness of health service’s audit arrangements ­systems, ensuring the early identification of
and the efficient and effective use of resources. risks and flags; and
The CFO is responsible to the CEO for ensuring • monitoring clinical governance implementa-
that proper accounting records and systems and tion and performance by continually review-
other records are maintained in accordance with ing key quality and safety indicators.
the relevant regulations.
The CFO may provide the Board with advice
on: Accreditation of the Health Service

• the financial statements; Accreditation is part of the regulatory framework

• compliance with legislation; that informs government and the community that
92 E. Loh and K. Lorenz

systems are present in health services to protect mental health and aged care accreditation bod-
the public from harm and improve the quality of ies as relevant.
health service provision.
The health service maintains accreditation
through an independent, external accreditation  ealth Service Governance
H
body. The accreditation process is a formal pro- Framework Checklist
cess of external review based on a series of
standards of care and processes. Health ser- The following table is a summary of the actions
vices are all required to be accredited by certain taken by the health service Board to ensure it
specified bodies. The health service is also acts in accordance with its eight governance
accredited and monitored against the relevant principles.

Principle Action
Establish ☑ Members of the board, the Chief Executive and the senior management of health service are
robust aware of the governance requirements for health service as set out in the health service
governance Governance Framework
and ☑ The governance structures required by the health service Board Charter, statutory instruments
oversight and government policy are established to provide effective oversight of clinical and corporate
frameworks responsibilities
☑ Accountabilities for health service delivery are clearly established at health service
☑ The authorities reserved for the Monash health Board and those delegated to management are
clearly documented and reviewed annually
☑ The Board—OH&S—Code of Conduct
☑ The Board and chief executive can demonstrate compliance with the eight corporate
governance standards approved by the Board
Effective ☑ The Board ensures that effective safety and quality systems and robust organisational
and structures are in place, that their performance is monitored and that health service responds
accountable appropriately to safety and quality problems
systems are ☑ The health service Board are responsible and accountable for ensuring the systems and
in place to processes are in place to support clinicians in providing safe, high-quality care, and in
monitor and ensuring clinicians participate in governance activities in accordance with the Safer Care
improve the Victoria Clinical Governance Framework
quality of ☑ The responsibility for designing and implementing systems and monitoring the effectiveness
the health of clinical care is appropriately delegated to managers and health care professionals with
services specific expertise. Clinicians and clinical teams are responsible and accountable for the safety
provided and quality of care they provide
☑ The Board ensures it receives systematic reports across the range of quality and safety
assurance activities
☑ The Board ensures that health service participates in regular assessments to maintain
accreditation to ensure that it meets quality and safety standards in service delivery
Set the ☑ The strategic plan is developed in accordance with Ministerial guidelines
strategic ☑ Agree an annual Statement of Priorities with the Minister
direction for ☑ Prepare an annual quality account report
the
☑ Quarterly reporting under the Victorian Health Services Performance Monitoring Framework
organisation
and its ☑ Monitoring service delivery performance
services ☑ Foster research and education by ensuring key partnerships are in place
☑ Ensure progress towards integrated care by ensuring key partnerships
Monitor ☑ Approve financial and operating plans and budges to ensure the accountable and efficient
financial and provision of health services and the viability of health service
service ☑ Monitor financial performance monthly
delivery ☑ Reviewing the capital plan
performance
☑ Approving the annual financial statements
☑ Reviewing and approving investment strategies in accordance with government policy
10 Public Health Service Governance: Principles and Framework 93

Principle Action
Maintain ☑ The Board complies with the Director’s Code of Conduct issued by the Public Sector
high Standards Commissioner
standards of ☑ Health service Board members disclose any conflicts of interest and declare personal interests
professional in accordance with government policy
and ethical ☑ The Board reviews and approves the health service Code of Conduct and ensures that its
conduct obligations are enforced
☑ A Fraud and Corruption Policy is in place
☑ A Gifts and Benefits Policy is in place and monitored
☑ All instances of improper conduct are managed properly and reported externally where
relevant
Involve ☑ Information is published on the internet, including quality of care reports, annual reports and
stakeholders privacy information
in decisions ☑ An effective complaints management process is in place.
that affect ☑ Health service has a Community Participation Plan which is embedded in the health service
them Strategic Plan
☑ Ensure that health service has programs demonstrating a commitment to diversity
☑ Aboriginal Liaison
☑ health service is responsive to statutory agencies such as the Coroner, IBAC, Mental Health
Complaints Commissioner, Health Care Complaints Commissioner and the Ombudsman
Establish ☑ A compliance program is in place to ensure the legal and policy obligations of health service
sound audit are identified, understood and managed
and risk ☑ Health service’s Enterprise Risk Management Framework has been developed in accordance
management with ISO 31000:2009 Risk management—Principles and guidelines
practices ☑ Health service complies with the Victorian Government Risk Framework, including the
requirement to arrange for its insurance with the VMIA
☑ An internal audit function is in place and accountable to the Board
☑ The Board regularly reviews health service’s governance framework including policies and
procedures
☑ The Board approves and regularly reviews the Delegations of Authority
☑ The Audit Committee reviews management controls and strategies associated with high and
medium risks
☑ The Board ensures that the Internal Auditors have access to the health service Board via the
Audit committee and has sufficient information to perform its function
Ensure key ☑ The health service Translation Precinct (MHTP) brings the research, education and clinical
partnerships expertise of health service, Monash University and the Hudson Institute of Medical Research
to develop and health service together
integrated
care,
research and
education
 Hospital Transformation:
How Is it Done? 11
Prasad Godbole and Derek Burke

Case Study by staff were raised, these were largely

ignored
The Mid Staffs ‘scandal’ [1] arose from concerns 6. The organisational culture did not promote
raised by the public into the treatment of patients safety
at the Mid Staffordshire Hospitals NHS 7. Staff morale was low and there were
Foundation Trust. These concerns were raised instances of bullying against staff who
over a number of years and culminated in the voiced concerns
Francis report in 2013 (https://www.health.org. 8. The main focus of the hospital was target
uk/about-the-francis-inquiry). As part of the driven priorities rather than patient safety
Francis report there were several key points 9. There was lack of honesty and transparency
noted: (candour) when things went wrong
10. There was a sense of denial at senior man-
1. Patients were not put first and care was not agement level that anything was wrong as
patient centred these shortcomings were felt to be similar to
2. Staffing was reduced and skill mix diluted to other Trusts in the region and hence ‘they
cut costs were no different’
3. Board meetings were held in private with
lack of communication that led to an element As a result of this inquiry, several key recom-
of mistrust. mendations (https://www.gov.uk/government/
4. There was significant disconnect between news/francis-report-on-mid-staffs-government-
management and frontline staff who felt accepts-recommendations) were made and
disengaged implemented throughout the NHS
5. Reporting of untoward incidents or concerns
was not encouraged and even when concerns 1. A common culture has been proposed
throughout the NHS
2. The report placed emphasis on the creation of
P. Godbole (*) a safety culture
Department of Paediatric Surgery, Sheffield 3. An organisation should have shared values
Children’s NHS Foundation Trust, Sheffield, UK between management and frontline staff
e-mail: Prasad.Godbole@sch.nhs.uk 4. The NHS must have a strong consistent lead-
D. Burke ership to motivate staff
Department of Emergency Medicine, Sheffield
Children’s NHS Foundation Trust, Sheffield, UK
e-mail: Derek.Burke@sch.nhs.uk

© Springer Nature Switzerland AG 2019 95

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_11
96 P. Godbole and D. Burke

5. Everyone employed by the NHS should have 3. Transparency: Staff have a right to know how
a questioning attitude, a rigorous approach their organisation is performing, when things
and good communication skills. go wrong and what is being done to manage
errors and prevent future errors occurring. It is
While patient safety is paramount and should essential that staff buy in to the transforma-
always be the foremost priority in any healthcare tional vision and the rationale for the transfor-
service, why do hospitals still find themselves not mational change for it to succeed.
performing to standards either from the patient 4. Organisational culture: Following the Francis
perspective or not being able to balance the report, many organisations have redefined
books? Let us look at the key requirements of their organisational culture. These new cul-
what can make a hospital successful tures are centred around organisational hon-
esty and a duty of candour when things have
Organisational Level gone wrong, encouraging incident reporting
1. Leadership: a lot has been written about lead- and most importantly putting patients first and
ership in healthcare organisations and what at the heart of everything the organisation
constitutes a good leader. However leadership does.
in the context of transformation can be a chal- 5. Performance management and accountability
lenging [2]. A leader has to be brave and bold framework: many organisations have an
and committed to the vision and values of the organisational structure which includes a
organisation. The leader should have a clear board and executive management team. The
vision about the short medium and longer non executive directors should be in a position
term endpoints for the organisation (where do to challenge the executive team and in turn the
we want to be) and be able to communicate executive team should be able to performance
this vision effectively to all staff members, manage those who are not performing ade-
particularly to the frontline staff. The leader quately. However it is still common in many
should be visible to staff and lead by his/her organisations to find executive management
own behaviour. At the same time the leader teams who do not challenge performance or
should be firm and be able to stand their poor outcomes. In government funded health
ground when they firmly believe a particular systems the executives may be restricted in
strategic direction is not right for the the actions they can take in relation to perfor-
organisation. mance management [5].
2. Communication and Engagement: engage- 6. Workforce: it is essential that organisations
ment between management and frontline staff have the right number and skill mix of work-
is key for the success of any transformation force to do the job. Frontline workforce both
project [3]. This engagement should be more clinical and non clinical should have the rele-
a ‘listening’ and not a ‘telling’ exercise. Far vant expertise and experience to provide high
too often this engagement of frontline staff is quality care. Support for the workforce in
only paid lip service in real life. Visibility of terms of funding for continuing professional
the management team is also of significant development should be a given. Lack of provi-
importance [4]. In many organisations front- sion of such funding can have the effect of
line staff report that they have no idea who demoralising the workforce and lead to
the management team is apart from the notion deskilling and risks to patient safety.
that they sit in the ‘executive corridor ‘. This 7. Engaging with external stakeholders: organ-
lack of engagement and open lines of com- isations cannot operate in isolation but have to
munication leads to a culture of them against operate as part of the overall healthcare sys-
us in relation to transformation. Engagement tem in which they operate. This may include
has to be truly collaborative and not simply a working with stakeholders such as commu-
gesture. nity based teams, school based teams for
11 Hospital Transformation: How Is it Done? 97

c­ hildren, mental health and social care teams. 2. Reduce waste (LEAN) (https://www.leanpro-
Working as a collaborative group can assist in duction.com/intro-to-lean.html): in the US, it
driving change across the spectrum of health is reported that about 30% of national health-
and social care. care expenditure does not make any difference
to or improve people’s lives [6]. Reduction in
Delivery of Patient Care waste and the use of LEAN or similar method-
1. Patient focused: any healthcare service pro- ologies in every process can yield significant
vider should have the patient at the heart of savings that can be reinvested in other key
everything they do. Treatment and care should priorities.
be provided based on what individuals in the 3. Financial priorities: every organisation will
organisation would expect if they or their fam- have key financial priorities for delivery of
ilies were patients themselves. The overall healthcare services. Funding for patient safety
patient experience should be a positive one. and quality improvements are important but
2. Outcomes oriented: Benchmarking against compete for funding with other priorities such
national and international standards for out- as IT systems and newer technologies such as
comes as well as devising a list of quality indi- AI as well as priorities for workforce to
cators for the organisation is important as it deliver. Balancing these competing priorities
allows an organisation to know whether it is is challenging particularly when there is no
doing a good job in the delivery of its objective criteria for deriving the optimum
service. allocation to each area. For example increas-
3. Data insights: the amount of data that an ing the workforce in the emergency depart-
organisation can generate is significant: activ- ment rather than transforming working
ity data and performance data by speciality practices may reduce funding allocation for
and individual clinician, outcomes data, peer the housekeeping department which may in
review data, financial data, quality data and turn lead to lower levels of cleanliness,
audit data. However this data is of little use if increased risk of hospital acquired infection
it has not been properly analysed to produce and poor patient experience.
information which allows executives and non-­
executives to make judgements about the
absolute and relative performance of the So What Is Transformation?
organisation.
4. Root cause analysis: where things go wrong, The term transformation is often used, even at
there needs to be a team of individuals skilled senior management level, to reflect minor service
in undertaking a root cause analysis of the changes or service improvements. Increasing the
problem. To ensure that the true root of the number of patients operated on in the operating
error is addressed. Currently many organisa- rooms is not a transformation but should be a
tions will only undertake a RCA for patient part of normal operational efficiency. However a
related safety incidents that cross a trigger risk whole scale change in working practices includ-
threshold rather than as a routine for failure in ing a radical shift in the number of hours or
other areas. days worked by OR staff including clinicians
and revised workforce planning to maximise
Financial the efficiency could be termed a transforma-
1. Cost effective: for any service to be viable, it tional change. It is important to differentiate
has to be cost effective and provide value for between a radical change and merely ‘tinker-
money. With emerging new technologies and ing’ around the edges. While the steps towards
treatments, there has to be good evidence that achieving a successful transformation are
they provide safe, cost effective interventions mainly focused on the senior management
and outcomes. team, it is essential for all members of staff to
98 P. Godbole and D. Burke

be aware of and engaged in the process. ships between them in terms of causal and tempo-
Transformation without staff engagement is ral linkage and identify areas for transformation.
doomed to fail. Transformation is a radical and Kotters 8 step transformation model [7] can be
irreversible change in the way a service is deliv- utilised and is outlined below:
ered, the way staff work and behave, how the
patients are engaged with a view to a sustained 1. Create a sense of urgency: the leadership
and measurable improvement in patient focused team need to start talking to every member
service delivery and outcomes. It is dynamic of staff about the need for transformation
iterative process which will span many years and and the urgency of this transformation. Staff
is a continual cycle of identify, transform, embed need to understand the organisational posi-
and review. tion in the marketplace and its strengths,
weaknesses, opportunities and threats. The
strategic short medium and long term vision
 teps to a Successful
S needs to be communicated effectively and
Transformation and How Is It Done? widely. This engagement needs to be by the
leadership team (executive management)
In any transformational change process, it is and not a delegated responsibility to the
important to identify the focus for the transfor- middle/junior management teams to the
mation. In the case of healthcare organisations exclusion of senior managers. Getting the
these may be divided into three intertwined broad staff talking about the change process will
interdependencies. allow negative thinkers and late adopters to
have a chance to discuss this and get engaged
1. Finance: is necessary to deliver the activity in the conversations. According to Dr Kotter
required to generate the revenue and opera- at least 75% of the workforce needs to be
tional capital for the hospital. Finance is also engaged and have a buy in for a successful
required to deliver the quality and safety transformation
agenda of the hospital 2. Establish a transformation group: this is key
2. Performance: the predicted activity that has to the success of a transformation project.
been budgeted for has to be delivered. Failure Enthusiastic leaders need to be signed up to
to deliver this will reduce revenue and opera- take on the roles within the transformation
tional capital. group. This is where the hierarchy of the man-
3. Quality and safety: patients nowadays have agement structure ends. The classical hierar-
greater expectations from their healthcare chy of executive board of directors, middle
providers than ever before and this trend is managers and frontline staff should not be
likely to continue. High quality care delivered slavishly adhered to. Cooperation of clini-
with patient collaboration (shared care model) cians and allied healthcare staff and non clini-
with good outcomes and good patient experi- cal staff as key stakeholders should be sought.
ence provides the potential of increased refer- It is the frontline staff who have the expertise
rals (patient choice), greater market share for and know how to able to solve problems or
the organisation and increased revenue. provide clinical input into different ways of
Regulators also play a role in providing achieving the goals of transformation. Very
insight into areas required for improvement often decisions are made at executive board
within hospitals. level with minimal representation from the
clinical teams which therefore destined the
The leadership team need to analyse the data transformation to fail. Utilising clinical cham-
available for all the above, review the interrelation- pions and making them feel worth their role in
11 Hospital Transformation: How Is it Done? 99

the transformation project will enable these 7. Persist in driving change: failure to achieve
clinicians to move the project forward. short term gains can lead to a demoralising
Currently in many organisations the role of effect on the teams involved. However positive
­middle managers is not well described apart reinforcement and regular encouragement and
from deputising or assisting senior managers feedback will enable teams to continue to drive
in various meetings about transformation change and be proud of their accomplishments.
projects. 8. Connect change to company culture: any
3. Define the end goal: the leadership team need transformational change has to be linked to
to be able to clearly and concisely describe the the organisational culture. In case of health-
end point of the transformation project and care organisations, the organisational culture
how it envisages getting to that end point. should be one that is patient focused in every
Many organisations do know the end point but aspect with a culture of transparency and hon-
are unable to identify how the change process esty. The organisation should be committed to
will be implemented. This leads to a disjointed continual improvement and any changes
and quite often segmented way of thinking should be in this context rather than the unfor-
which is neither coherent or rational. tunate issue of financial savings that often
4. Share the end goal: once the end point is iden- forms the basis of transformational change.
tified, this must be shared with all staff mem-
bers through face to face meetings.
Communications by email or various other  ase Study 2: Putting
C
means can lead to uncertainty and can raise It into Practice
more questions than are answered. Visibility
of the leadership team is important when shar- A hospital in the south of England was put into
ing the vision and the end goal. special measures by the regulatory bodies—the
5. Encourage participation and remove obstacles CQC [8] and MONITOR [9] due to concerns
to participation: transformation is a dynamic over patient safety and quality of care. This was
process and does not happen overnight. There as reported by the BBC precipitated by the death
is always resistance to change and active dis- of a 10 year old girl [10]. The following Table 11.1
cussion and collaborative efforts goes a long demonstrates how the transformation of the hos-
way in overcoming the resistance to change. pital from being in ‘special measures’ to achiev-
There may be many hurdles and obstacles ing a ‘good’ status was achieved.
encountered in encouraging individuals to
participate and any major hurdles should be
removed. This may be giving clinicians time Conclusion
away from their clinical activity to participate
in the transformational change rather than Transformational change in a hospital setting is
expecting them to do this as an added ‘extra’ challenging. Most transformational changes fail
to their role. due to lack of leadership, vision, engagement and
6. Share and celebrate short term gains: transfor- communication. A whole team approach is nec-
mation gains should target ‘low hanging fruit’ essary rather than an us (management) and them
and gains that are achievable in the short term (clinicians) approach. Multiple stakeholders out-
without unnecessary expense. There is noth- side the normal hierarchy should be engaged in
ing more rewarding then for teams to be con- the process. Regular feedback and incentivising
gratulated for achieving their short term goal short term gains assists in a continual transforma-
and this motivates the team to persevere with tion process to achieve the long term vision
the transformation. (Table 11.2).
100 P. Godbole and D. Burke

Table 11.1 Hospital transformation case study

No Corrective action Commentary
1 Chairman, CEO, executive Poor Leadership was replaced with a team that had the leadership
management team replaced qualities to drive the change
2 Data analysed, Root causes found, The team appointed and replaced managers with those who were able
problems identified, key priorities to undertake and provide a coherent explanation for the data. This
agreed allowed the team to agree priorities
3 Clinical engagement and visibility A meeting was held every morning in the canteen where anyone was
welcome to attend and voice their concerns. The meeting lasted 20 min
and was lead by the CEO. Similar meetings were held across
departments by executive team frequently allowing them to gain an
understanding of the problems but also allowing collaboration with the
frontline workers
4 Clinical champions appointed Clinicians as leaders were involved and engaged in the process
5 Service improvements identified, As part of the transformation process, several programs of work were
processes changed identified and commenced leading to service improvements and better
patient safety
6 Feedback to staff Communication constantly maintained
7 Hospital taken out of special Hospital achieved key regulatory requirements and standards of patient
measures safety and quality
8 Hospital has significant financial The hospital had to invest in the turnaround process. This caused them
deficit to go into deficit. However they have a robust plan for financial
recovery over 3 years. It is a common mistake for hospitals to have
finance as their key priority in terms of balancing the books. Sensible
and strategic investment is important as long as a strong plan for
recovery is agreed

Table 11.2 Self assessment ‘health’ checklist for healthcare organisations

Green (2 points) Amber (1 point) Red (0 Points)
Leadership
Does the chairman and non-executive directors Yes No
have a track record in delivery of healthcare
transformation
Is the CEO experienced in leading a executive More than 5 years 1–5 years Less than 1 year
management team
How many transformation projects have the More than 5 1–5 None
executive management team led that have been
successful and can be communicated to staff in
the last 5 years
What percentage of staff know the executive More than 75% 25–75% Less than 25%
management team by face and their role
How many times a week do members of the Every day 2–4 times a week Less than twice a
management team do a walk around the week
hospital gaining insight into daily operations
and challenges
How many times a week are open forums held Every day Every week Less than monthly
and led by a member of the executive team
How often are views of the workforce sought Weekly Monthly Annually
What percentage of the workforce would agree More than 75% 25–75% Less than 25%
that there is clear communication and
engagement about the vision, strategy,
rationale and implementation of a
transformation program
What percentage of the staff are aware of the More than 75% 25–75% Less than 25%
vision, values and organisational culture
11 Hospital Transformation: How Is it Done? 101

Table 11.2 (continued)

Green (2 points) Amber (1 point) Red (0 Points)
Do all managers have job descriptions and key Yes all have job 50–75% have job Less than 50% have
performance indicators available for review at descriptions and KPI descriptions and job descriptions
any time KPI and KPI
Is there evidence of performance management Documentary Documentary Documentary
and remedial actions as a result evidence for more evidence 50–75% evidence less than
than 75% of teams/ 50% of the time
managers
Has there been any compulsory redundancies Yes No
made from the hospital in the last 5 years due
to poor performance
Workforce
Are there enough clinicians for the activity to Yes No
be delivered
Is there the correct skill mix of clinicians Yes No
Are clinical leaders identified and have they Yes No
got a track record in transformation
Have clinicians been supported to develop Yes No
skills as leaders
Are clinicians supported financially for CPD Yes Partially funded No
What percentage of clinicians would state they More than 75% 50–75% Less than 50%
are actively encouraged to engage in the
hospital operations and change processes
What percentage of clinicians feel the hospital More than 75% 50–75% Less than 50%
is too ‘management heavy’ or not fit for
purpose
What is the incidence of long term sickness Less than 1% 1–3% Greater than 3%
amongst clinicians
How many clinicians as a percentage of Greater than 75% 50–75% Less than 50%
clinical workforce attend open forums if
organised
What percentage of identified clinical leaders Greater than 75% 50–75% Less than 50%
are in charge of transformation projects
Does the hospital have an adequate nurse Yes No
establishment across all departments
Is the nursing skill mix appropriate Yes No
What percentage of nurses feel they are Greater than 75% 50–75% Less than 50%
engaged in hospital transformation
Are nursing leaders identified and contribution Yes No
to transformation documented
What is the sickness incidence amongst 1–2% 3–5% Greater than 5%
nursing staff
Are nurses supported for CPD financially Yes No
Non clinical workforce and allied healthcare workforce
Are there adequate staff and skill mix Yes No
Are there staff able to undertake RCA and how Yes more than 5 Currently 3–5 No less than 3
many
How many data analysts form part of the Yes more than 3 Currently 1–3 None
workforce who can interrogate the data for
answers
What is the overall staff sickness 1–2% 2–5% Greater than 5%
Is the staff sickness increasing, same or Decreasing Same Increasing
decreasing over the last 5 years
(continued)
102 P. Godbole and D. Burke

Table 11.2 (continued)

Green (2 points) Amber (1 point) Red (0 Points)
Delivery of patient care
Does the hospital have robust evidence to Yes No
demonstrate evidence based care
Have the patient related safety incidents Decreasing Same Increasing
remained the same, decreased or increased
over the last 5 years
How many complaints have been received and Decreasing Same Increasing
have they stayed the same, increased or
decreased over the last 5 years
How many deaths have been avoidable and are All Some None
all deaths reported and investigated
How many serious incidents have been Decreasing Same Increasing
reported annually and have these increased,
decreased or stayed the same over the last
5 years
What percentage of patients/families would Greater than 98% 85–98% Less than 85%
recommend your hospital to relatives/friends
Has your hospital received a poor rating for No Don’t know Yes
any service by regulators
What percentage of patients/families would Greater than 98% 85–98% Less than 85%
describe the hospital as clean and pleasant
What percentage of staff, families and patients Greater than 98% 85–98% Less than 85%
describe the catering facilities in the hospital
as good
What percentage of patients per annum have None Less than 1% Greater than 1%
contracted avoidable complications such as
DVT, MRSA, pressure ulcer, venous ulcer,
C. Difficile
What percentage of patients and families Greater than 98% 85–98% Less than 85%
surveyed would state they have met a member
of the management team to ask their views of
the service provided
Does the hospital publish outcome data by Yes No
clinician on their website
Finance
Is the hospital in surplus, break even or in Surplus Break-even Deficit
deficit
Is the hospital delivering on activity in terms Yes In some No
of performance across all specialities specialities
Is the hospital achieving any internal standards Yes In some No
of performance and productivity specialities
Is there a documented integrated root cause Yes Partial No
analysis identifying key factors for the
financial position
Is there a documented investment and recovery Yes No
plan that is robust
Is there any regulatory pressure on the hospital No Yes
for financial stability
Are transformation and investment projects on No Some plans are on Yes, all plans are
hold due to financial considerations hold on hold
What percentage of the workforce feel finance Less than 25% 25–75% More than 75%
is a key priority for the hospital as well as cost
cutting
11 Hospital Transformation: How Is it Done? 103

Table 11.2 (continued)

Green (2 points) Amber (1 point) Red (0 Points)
Organisational
Number of successful litigations over the last Decreasing No change Increasing
5 years
Percentage of budget over the last 5 years on Decreasing No change Increasing
settling claims of all types
Staff retention over the last 5 years More than 85% More than 75% Less than 75%
Note: maximum score = 114. 85% of maximum = good no changes needed, continue transformation, efficiency proj-
ects; 50–75% of maximum = needs remedial action; Less than 50% = needs urgent remedial intervention

1995. Available at https://hbr.org/1995/05/

References leading-change-why-transformation-efforts-fail-2.
5. Lutwama GW, Roos JH, Dolamo BL. Assessing
1. Holmes D. Mid Staffordshire scandal highlights NHS the implementation of performance management of
cultural crisis. The Lancet. 2013;381(9866):521–2. health care workers in Uganda. BMC Health Serv
2. Walsh N. The leadership challenges of sustainability Res. 2013;13:355.
and transformation plans. London: The Kings Fund; 6. Obama B. United States Health care reform: progress
2016. Available at https://www.kingsfund.org.uk/ to date and next steps. JAMA. 2016;316(5):525–32.
blog/2016/04/leadership-challenges-stps. 7. Webster V, Webster M. Successful change man-
3. Daneshgari P, Moore H. Organizational transforma- agement — Kotter’s 8-Step Change Model.
tion through improved employee engagement – “How Available at https://www.leadershipthoughts.com/
to use effective methodologies to improve business kotters-8-step-change-model/.
productivity and expand market share”. Strategic HR 8. https://www.cqc.org.uk.
Rev. 2016;15(2):57–64. 9. https://improvement.nhs.uk.
4. Kotter JP. Leading change: why transforma- 10. https://www.bbc.com/news/uk-england-​essex-25309619.
tion efforts fail. Harvard Business Review.
 Part VI
Sustainability
 Sustainable Hospital
Transformation and Beyond 12
Stephen Stericker and Dawn Lawson

Introduction It is critical to recognise that any transformation

sits within a wider system of constant change that
Much has been written about improvement and will either enable sustainable change or present
transformation in the NHS and is covered else- challenges to overcome. We hope this chapter
where in this book. The most significant chal- provides some practical advice that can be con-
lenge in the transformation process is ensuring textualised to help you ensure the transformation
that change or improvement is sustained over outcomes that you work on are sustained.
time, after the ‘initiative’ has ended. Often, when
embarking on a transformation initiative, there
can be little, if any, thought put into the sustain-  he Context for Sustainability
T
ability of the transformation. Similarly, there is in NHS Acute Hospitals
sometimes inadequate attention paid to the evalu-
ation of the impact of the transformation. Thinking about sustainability in acute hospi-
In our experience of undertaking transforma- tals means thinking about the local regional and
tion and seeking to ensure that it is sustained, national environment or context within which
there are several key elements that must be con- they are operating. In 2014, the NHS 5 Year
sidered from the outset. Our conclusion is that Forward View [1] emphasised the need to get
whether or not the transformation will be sus- serious about prevention.
tained must depend from the start on how you The future health of millions of children, the sus-
engage, construct implement and evaluate it, tainability of the NHS, and the economic prosper-
rather than being too pre-occupied with the sub- ity all now depend on a radical upgrade in
ject of the transformation itself. prevention and public health [1, p. 9]
We will discuss the context for sustainability in
NHS acute hospitals and describe guidance from The NHS 5 Year Forward View describes three
various sources. We then move on to describe the improvement opportunities: a health gap, a qual-
importance of working in partnership with oth- ity gap, and a financial sustainability gap. In
ers, both internal and external to an organisation. order to address these gaps, it explores opportu-
nities to steer the ‘triple integration’ of primary
and specialist hospital care, of physical and men-
S. Stericker, PhD (*) tal health services, and of health and social care.
Care to Innovate, NHS and Social Care, York, UK
e-mail: stephen_stericker@sky.com It is considered to be the role of the NHS and
a well-functioning public health and social care
D. Lawson
Liverpool Health Partners, Liverpool, UK sector to bring about any necessary changes.

© Springer Nature Switzerland AG 2019 107

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_12
108 S. Stericker and D. Lawson

The Care Quality Commission published The oping “a clinically, operationally and financially
state of care in NHS acute hospitals: 2014–2016 sustainable pattern of care and implementing
[2]. The report identified demographic population strategic changes”. The plan makes it clear that
changes leading to rising demand for services, providers will be required to transform services
coupled with economic pressures. The financial by developing and adopting new care models
challenge was reported to be significant for all and new models of accountable care. A key pri-
NHS providers, with a 2015/2016 deficit of £2.45 ority for NHS Improvement is to support those
billion and 60% of all acute trusts forecasting a organisations seeking to become accountable care
year-end deficit for 2016/2017. organisations (ACOs). It is expected that ACOs
Professor Mike Richards stated the following: will manage an integrated budget for primary,
community, mental health and acute care and be
The NHS stands on a burning platform—the model
of acute care that worked well when the NHS was
responsible for improving the health outcomes for
established is no longer capable of delivering the a defined population.
care that today’s population needs. The need for The context for the wider public sector is
change is clear, but finding the resources and
energy to deliver change while simultaneously pro-
also one of severe pressures, with Government
viding safe patient care can seem near impossible. funding for local authorities having fallen by an
[2, p. 4] estimated 49.1% in real terms from 2010–2011
to 2017–2018. [6, p. 4]. Alongside reductions
In 2017, the Next Steps on the NHS 5 Year in funding, local authorities have experienced
Forward View supported the need for strategic growth in demand for key services, as well as
partnerships to plan and integrate the commis- absorbing other cost pressures. It is therefore not
sioning and delivery of health and care services: surprising that acute NHS hospitals have experi-
We now want to accelerate this way of working to enced continuing delays in discharging patients
more of the country, through partnerships of care into overstretched community and social care
providers and commissioners in an area services.
(Sustainability and Transformation Partnerships).
Some areas are now ready to go further and more To address the ‘burning platform’ of sustain-
fully integrate their services and funding, and we able health and social care services, a consis-
will back them in doing so (Accountable Care tent policy solution across the NHS and Local
Systems). Working together with patients and the Government has seen guidance developed to
public, NHS commissioners and providers, as well
as local authorities and other providers of health encourage health and social care commission-
and care services, they will gain new powers and ers to work in more integrated ways. The Local
freedoms to plan how best to provide care, while Government Association and the NHS published
taking on new responsibilities for improving the Integrated Commissioning for Better Outcomes:
health and wellbeing of the population they cover.
[3, p. 5] A Commissioning Framework [7] to support
local health and care economies to strengthen
Ham et al. [4] published a report that reviewed and progress their integrated commissioning
proposals in 44 Sustainable Transformation Plans and joint working further for the benefit of local
submitted to NHS England. Key messages for the people.
acute hospital sector included planned reductions This solution to sustainability is also sup-
in the number of acute hospital beds, using exist- ported by organisations outside of the NHS and
ing services in the community more effectively to Local Government. For example, The Health
moderate demand for hospital care and reconfig- Foundation submission to the Public Accounts
uring hospitals. Committee inquiry on sustainability and trans-
NHS Improvement affirmed their commitment formation in the NHS (February 2018) focussed
to support the implementation of priorities con- very much upon thinking systemically and
tained within the Next Steps on the NHS 5 Year system integration. The submission identified
­
Forward View. The NHS Improvement Business three key ways that national bodies can support
Plan 2017–2019 [5] reflected a focus on devel- cross-­organisational change:
12 Sustainable Hospital Transformation and Beyond 109

1. Future focus is needed on what the national Public Health England to work across the NHS,
performance and governance frameworks public health and social care system. When the
should look like—they must build in the time SDU talks about sustainability, it means helping
and headspace needed to carry out redesign, the public sector to reduce emissions, save money
allowing for experimentation and failure. This and improve the health of people and commu-
is important not just for the most advanced nities. At an environmental level this includes
systems (as is currently being tested with inte- addressing issues such as energy, travel, waste,
grated care systems) but also for those at a procurement, water, infrastructure adaptation and
more formative stage of developing new the built environment. At a wider level it includes
models. adaptation of health service delivery, health
2. National messaging should focus on the core promotion, tackling the wider determinants of
aims of system change and not simply on health, corporate social responsibility, individual
restructuring. It should encourage sites to responsibility and developing new sustainable
answer the question: ‘how can care be models of care. (https://www.sduhealth.org.uk).
improved for patients in this area?’ as opposed In 2013 the NHS established a Sustainability
to ‘how can this area become a new care Campaign, consisting of an annual Sustainability
model?’ Day. NHS and Health professionals are encour-
3. Investing in robust local and national evalua- aged to “showcase how they are driving sustain-
tion will enable sites to understand if changes ability whilst celebrating their achievements
are improving care. This will make sure what and engaging with staff, patients and visi-
works and why is shared and that others can tors.” (https://www.nhssustainabilityday.co.uk/
learn from their mistakes. [8, p. 5] about-sustainability-day/). In the context of the
Sustainability Campaign, sustainability means
The case for sustainability and acute, hospital-­ taking action in the three key areas of saving
based healthcare has been squarely located within money, reducing impact on the environment and
a paradigm that uses words or phrases such as delivering higher standards of patient care.
reconfiguration, integrated commissioning, inte- The NHS Innovation and Improvement
grated systems, joint working, prevention, part- Agency [9] defined sustainability as follows:
nerships and transformation. If sustainability is Sustainability: new ways of working and improved
about being part of a system, then leaders from outcomes become the norm. Not only have the pro-
across the sectors will be reflecting upon their cess and outcome changed, but also the thinking
contributions to a system that collaborates in pro- and attitudes behind them are fundamentally
altered and the systems surrounding them are
viding sustainable health and care? transformed in support. [9, p. 9]

The NHS Institute for Innovation reported

 aking Sense of Sustainability
M that many healthcare improvement initiatives did
in NHS Acute Hospital Care not continue, stating that there is evidence that
one in every three improvement initiatives fails
The term sustainability can mean different things to achieve the objectives they set out to. The
to different people. When thinking about sustain- implications of this failure rate are compromised
ability, it is helpful to reflect upon what we mean patient experience, a waste of resources, finances,
by the word, what is it that people are trying to staff time and a risk to their future engagement
achieve and in what context? For many years, in opportunities to transform services [9, p. 25].
NHS development organisations have provided Two major challenges were identified:
practical guidance and support to the NHS in
pursuit of the goal of sustainability. 1. The improvement evaporation effect or initia-
The Sustainable Development Unit (SDU) tive decay. This is what happens when an
was established and funded by NHS England and improvement has been implemented but is not
110 S. Stericker and D. Lawson

embedded into the organisations ‘business as The Model was not designed to assess whether
usual’ and things reverts to how they were a department, whole organisation or health com-
before change was made. munity is likely to sustain an innovation or trans-
2. Isolated improvements or improvement formational change. It was recommended that its
islands. This is what happens when an use should be linked to a specific improvement
improvement is sustained within a team or project or initiative. The model supports the
service area, but doesn’t spread more widely implementation of change and in so doing recog-
through the organisation or across other nises that, at project or system level, any improve-
organisations [9, p. 8] ment is dependent upon change as an essential
component for sustainability. As new evidence
Figure 12.1, produced by NHS I&I [9], illus- emerges, and clinical practices change with new
trates key enablers that should exist within organ- technologies or medicines, then a continuation
isations aiming to sustain improvement. of a new way of working is less important than
In order to provide organisations with a an organisations ability to constantly adapt or to
practical tool, the NHS I&I [10] developed a transform when today’s change becomes yester-
Sustainability Model and Guide. The guide day’s way of doing things.
states that the most successful organisations are It is clear that sustainability has many dimen-
those that can implement and sustain effective sions that range from implementing a small-
improvement initiatives which lead to increased scale project to the transformation of the way an
quality and patient experience at lower cost. The organisation delivers its services through to how
Sustainability Model aims to identify strengths a system might continue to be financially viable,
and weaknesses in implementation plans and pre- reduce its environmental impact and improve the
dict the likelihood of a sustainable improvement quality of care for an entire population. At the
initiative. The model, illustrated by the NHS I&I level of, for example, an acute hospital trust, we
in Fig. 12.2, identifies the main factors affect- suggest that sustainability requires the organisa-
ing sustainability of an improvement initiative tion to focus upon their capacity and capability
and groups them under the three themes of staff, to continually change. However, organisations
process and organisation. Each theme has several work within a complex and multi-faceted system
associated factors against which organisations or of health and care that requires the sum of all the
teams can self-assess the likelihood of implement- parts of the system to collaborate in order to col-
ing an improvement and of sustaining any change. lectively adapt to economic, political, social and

Sustainability

1 Supportive 2 Structures 3 Effective 4 Effective 5 Culture of 6 Formal

managament to foolproof delivery collaboration improvement capacity -
structure change so supported by and a shared with engaged building
that robust, sense of the staff and programs
embedding transparent systems to be patients
takes place feedback improved
systems +
POSA cycles

Fig. 12.1 Key enablers for sustainable improvement [9, p. 18]

 12

Monitoring Progress 35

43 Training and Involvement

51 Attitudes

Adaptability 27
Staff
59 Senior Leaders

Credibility of Evidence 19
Process
Sustainable Hospital Transformation and Beyond

65 Clinical Leaders
Benefits beyond helping patients 09
Organisation

Infrastructure 77

71 Fit with Goals and Culture

Fig. 12.2 The NHS Innovation and Improvement model for sustainability [10]
111
112 S. Stericker and D. Lawson

environmental changes. Sustainability requires Baker [12] reviewed a small group of high
leaders to think ‘whole system’ and how they can performing healthcare systems: Jonkoping
overcome challenges that mitigate against work- County Council, Intermountain Healthcare,
ing in this way. Henry Ford Health System and VA New
England Healthcare System. Baker identified
ten key themes underlying the sustainability of
 hat Can We Learn from Other
W the care systems:
Health Systems?
1. Consistent leadership that embraces com-
Dougall et al. [11] have described and reviewed four mon goals and aligns activities throughout
organisations who have been recognised for their the organisation
place-based transformation work: The Bromley The systems had strong senior leadership,
by Bow Centre in East London; Birmingham and but leadership in the systems was also dis-
Solihull Mental Health Trust, Northumbria Health tributed and collective
care NHS Foundation Trust and Buurtzorg (from 2. Quality and system improvement as a core
the Netherlands). The review draws out a number strategy
of key challenges the systems faced: Transformation was a slow process, so a
clear and sustained strategy over time was
1. Overcoming inertia—creating a receptive important
context 3. Organisational capacities and skills to sup-
Staff were very engaged and motivated by port performance improvement
improving care, but many people did not feel Consistent effort was made to enhance
able to act as change leaders skills and capabilities among staff and to
2. The concept of power change the vision that drives provision of
‘Power’ was important in the transforma- services
tional change stories, sometimes as a barrier 4. Robust primary care teams at the centre of
that could often be disempowering. But, where the delivery system
power was shared it became empowering Integrated, effective primary care was a
3. ‘Old power’ and ‘new power’ vital part of creating a better performing
Power dynamics were important in the sto- health care system overall
ries. For example, ‘old power’ held by the few 5. Engaging patients in their care and in design
and closely guarded versus ‘new power’, of care
enabling people at grassroots level to exercise Whole person care, comprehensive com-
agency. There were some examples of the munication and coordination, patient support
shift from old to new power. and empowerment
4. Maintain dual focus 6. Promoting professional cultures that support
Working effectively within current con- teamwork, continuous improvement and
straints, whilst championing fundamentally patient engagement
different structures and approaches to support A real commitment to building a profes-
transformation was challenging but that a dual sional culture that encourages and regards
focus is needed improvement, patient engagement and
5. Difficult choices teamwork.
There were tensions between radical inno- 7. More effective integration of care that pro-
vation and the need to protect people from motes seamless care transitions
harm, between the pace of change and the Recognising the interdependence between
time it takes to fully engage people, the bal- system levels means that quality improve-
ance between providing acute are compared to ment must also improve transitions of care
having a longer term preventative focus. between the parts of the system
12 Sustainable Hospital Transformation and Beyond 113

8. Information as a platform guiding Much has been written about organisational

improvement culture in the NHS, which we won’t discuss
Focus on identifying and measurement to here, except to say that organisational culture is
support improvement, with local teams col- a significant factor in the sustainability of trans-
lecting their own measures of clinical perfor- formation. If directorates or departments are
mance to track their progress toward clinical encouraged and incentivised to compete against
goals each other, even in seemingly innocuous ways,
9. Effective learning strategies and methods to then working together on a change or transforma-
test improvements and scale up tion project will be so much harder. For example,
Close linkages with other organisations, the sustainability of tackling the pressures faced
and have proactively identified new methods by Accident and Emergency Departments will
and tools and adapted them to local stand a greater chance of success if the Hospital
environments. is able to transfer people onto an appropriate
10. Providing an enabling environment buffering ward by creating space through reducing the
short-term factors that undermine success length of stays in the Hospital. This could then
All the systems have faced major chal- require, for example, initiatives that facilitate the
lenges, but achieved by adopting a long-term timely resolution of any diagnostic tests and the
strategy for improving care, working to prompt prescribing of medicines to enable earlier
develop talent and create a focus on provid- discharge.
ing patient centred care. There is a real challenge for leaders of organ-
isations to implement what they consider ‘rig-
orous’ performance management, whilst not
Collaboration and Working creating negative side effects. There is noth-
in Partnership ing like competition between teams to create
an insidious culture where teams cannot look
As well as considering the transformation proj- beyond their own boundary to support transfor-
ect itself, leaders will understand how to work in mation projects.
partnership within an individual organisation and
also across a system. The health and care system  ollaboration Outside the Organisation
C
is a complex environment, with many compet- Fragmentation and competition within a health
ing demands and pressures. This environment system is not suited to solving the complex chal-
can thwart the most promising transformation lenges that all health systems are facing. This is
projects and working in partnership is a particu- now broadly recognised, and a significant shift in
lar skill, even when the transformation remains language can been seen across policy documents
within a single organisation. and health committee reviews. It is recognised
that health incorporates mental, physical and
 ollaboration Within the Organisation
C social wellbeing and many factors contribute to
Whilst an organisation is a single entity, it is our good health such as quality housing, education,
observation that how well the organisation coop- employment, community networks and others
erates internally is a significant factor in (a) how [13]. Indeed, the direction of travel in the NHS
well an organisation can initiate improvement or is very much on partnerships and integrated care
transformation projects and (b) how well they systems.
will sustain them. This is because many projects This approach provides a significant psycho-
are not contained within one team or department. logical challenge to sovereign organisations that
Therefore, if there isn’t an organisational culture have survived thus far by competing with their
of working together to solve a common problem, peers. It requires leaders to work together, span-
sustainability of transformation across the organ- ning boundaries between organisations whilst
isational will be a struggle. prioritising patient care, rather than the success
114 S. Stericker and D. Lawson

of their organisation or component of the system a key enabler for the success and sustainability of
[14]. The complexity of transformation proj- health and wellbeing improvement initiatives in
ects in these circumstances is infinitely greater, care homes for older people. It is our experience
especially if the individual organisations have that failure to value and transform relationships
a competitive culture and struggle to cooperate often leads to change efforts failing or not being
internally. However, more integrated and system sustained.
wide approaches can be achieved and there are
excellent initiatives across the UK where com-
missioners, primary care, acute sector providers, How to Work Across a System
social care and the independent sector have col-
laborated to ensure the timely discharge of peo- The evidence from other integrated care sys-
ple from hospital back into their own homes or tems confirms the importance of the time
into intermediate care services. needed to build relationships to establish qual-
Genuine partnership approaches that engage ity efforts towards local transformation [11, 14,
the whole of the system are essential when facing 17, 19]. Hulks et al. [20] have drawn upon the
the challenges of most health and care systems work of Michael West and others, and identi-
[15]. Both leaders and organisations have been fied five factors that facilitate working across
rewarded for working competitively for decades systems:
and are now required to work differently. They
are required to work collectively and build a 1. Develop a shared purpose and vision
cooperative, integrative leadership culture—in This requires a shift from reactive problem-­
effect, collective leadership at the system level solving to building positive visions for the
[16]. In addition, there is the challenge of statu- future. This includes confronting difficult
tory legislation which requires them to compete choices about the present reality as part of
as service providers, which in part is a genuine working towards an inspiring vision
barrier, but can also be used as a convenient 2. Have frequent personal contact
‘excuse’ to maintain the status quo. Collaboration is a team activity, a contact
Working collaboratively across systems is sport that cannot be conducted at distance. It
required to address ‘wicked’ problems, but col- requires leadership to establish the rapport
laboration is not easy when the health and care and understanding as a basis for a collabora-
system remains fragmented and regulators can tive relationship
often operate inconsistently. In working across 3. Surface and resolve conflicts
systems, we have observed the power of indi- Collaboration is not easy nor straightfor-
vidual leaders who possess excellent skills in ward. Agreements will go hand in hand with
building positive relationships and adopt prag- disagreements. If they are allowed to fester
matic, yet effective approaches when negotiating and undermine relationships and trust, dis-
system wide barriers such as competition. Senge agreements can be fatal to collaboration.
et al. [17] conclude that transforming systems 4. Behave altruistically towards each other
is ultimately about transforming relationships Leaders who are now seeking to collabo-
among people who shape those systems. rate with each other, will have often found
A themed review by the NIHR Dissemination themselves competing in the past. This means
Centre [18], entitled Advancing Care: Research moving from a win-lose style of negotiation to
with care homes, concluded that the research win-win.
evidence clearly supports partnership working 5. Commit to working together for the longer
between care homes, the NHS and wider stake- term
holders at individual, organisational and system This matters because of the investment of
levels. Determined efforts to build and maintain time and energy needed to build effective
positive working relationships were identified as relationships.
12 Sustainable Hospital Transformation and Beyond 115

The nature of health care provision in the styles that were most successful in the different
NHS has changed significantly over the last few contexts.
years with a move towards system thinking. This The Cynefin Framework [23] summarises the
means understanding how working in partnership different contexts and leadership approaches. It
will ensure that a transformation is sustained. As provides a clear way of categorising the context
the NHS is trying to operate more as a system, of the challenge or problem that a transformation
rather than a collection of individual organisa- is intended to address. In our experience, very
tions, recognising the impact of the environment little effort is put into really understanding and
and context must be considered in relation to any defining the problem that is trying to be solved.
transformation. The same is true of defining success measures.
We have often found very little relationship
between the problem that is trying to be solved
Environment and Context and what ‘good’ looks like. Without a clear,
rational line of thought from start to end, often
Understanding Context well-­meant transformation and improvement ini-
tiatives end up being confusing in their ambition
Ensuring that transformation is sustainable starts and tend not to meet the expectations of all stake-
at the early planning stage. At the outset of any holders. This can then lead to those involved in
transformation, it is time well spent to under- such programs to be disillusioned and less likely
stand the type of problem or challenges that any to put psychological effort and physical commit-
change is seeking to address. Different types of ment into transformation projects in the future.
challenges need different approaches, both in Cynefin, pronounced ku-nev-in, is a Welsh
terms of leadership style and the solution design. word that signifies ‘place’ or ‘habitat’, but also
This is commonly overlooked, with one style of the multiple factors in our environment [22].
approach being used across different challenges Context is a significant factor which should
for which it is not appropriate. shape the response to the problem, a one size
By working in partnership, it offers leaders an fits all response is not an effective approach.
opportunity to rethink and to create completely The Cynefin framework identifies five cause and
different, more effective ways of addressing chal- effect domains: complex; complicated; chaotic;
lenges [11]. Working across an organisation or simple; disorder. A few words on each context
system is however more complex and provides are below.
a very different operating context for leaders.
When working in a complex environment with Simple Context The simple context is when
little certainty, linear cause and effect models there are ‘known—knowns’ to address the prob-
are not appropriate, and a flexible approach is lem. For example, we know that anti-coagulating
required [21]. patients with atrial fibrillation will reduce their
Working in a complex environment provides risk of stroke. Simple does not mean easy, but
a series of often paradoxical challenges for lead- there is a cause and effect relationship, it is lik-
ers. To work successfully in a system, leaders ened to following a recipe.
must have a good understanding of context and
the ability to embrace complexity and paradox. Complicated Context In this context there may
There are frameworks that support leaders oper- be several potential solutions, so some testing
ating in complex environments to address real and adjusting is required. It is likened to sending
world challenges (e.g. [22]). The Cynefin frame- a rocket into space, much is known but there is
work offers a way to understand different con- still some testing and input from experts required.
texts [22]. Snowdon has tested and applied the
framework in different leadership contexts, sec- Complex Context In this context little is known,
tors and environments to identify the leadership there are many ‘unknown-unkowns’ which means
116 S. Stericker and D. Lawson

to address problems in this context, a testing pathways that improve patient flow through
approach is required. It is likened to raising a out of hours services.
child, as what works in one situation may not • Implementing a community pharmacy project
work in another and generalising is often not designed to reduce prescribing demand on out
possible. of hours GP services
• Implementing an out of hours direct booking
Chaotic Context In this context there is no rela- initiative designed to enable NHS 111 ser-
tionship between cause and effect, the priority is vices to book appointments directly into GP
to establish order and stability. Crisis and emer- practices.
gency scenarios often fall into this domain e.g. • Implementing a Clinical Advisory Service
the attack on the Twin Towers in New York. (CAS) to provide care navigation and clinical
advice to 111, 999 & front line healthcare
Disorder When it isn’t clear which of the other professionals
four domains is dominant, you are in a ‘disorder’ • Ensuring the coordinated development and
situation. provision of urgent treatment centres

It is possible for a problem to move through It is often the case in health and social care
different domains, starting as ‘complicated’ and that there are multiple initiatives happening at
becoming ‘simple’. As highlighted earlier, an the same time and these can be locally, region-
example of a complex challenge is improving the ally or nationally led. It can be difficult to see
performance and outcomes of NHS urgent and how they fit together and how their impact might
emergency care departments. For many years be evaluated, not as individual projects but upon,
the NHS urgent and emergency care services for example, the operations of an urgent and
have been under pressure with continued growth emergency care system of multiple interven-
in levels of emergency admissions and from tions and involving multiple care providers and
delayed transfers of care when patients require commissioners.
admission to a hospital ward or are ready to leave Taking one of the initiatives cited as an
hospital. NHS England led the development of example, implementing an out of hours book-
a national programme of activities designed to ing initiative to enable NHS 111 services to
improve the urgent and emergency care (UEC) book appointments directly into GP practices. If
system so patients “get the right care in the right patients have been triaged by NHS 111 and cat-
place, whenever they need it”. egorised as not immediately urgent, they would
A number of different interventions were iden- not be offered an appointment with an out of
tified that could have an impact on the quality and hours doctor. However, it was found to be the case
effectiveness of care. It is the task of local leaders that many patients would attend A&E as a default
to collaborate and take a ‘system leadership’ role way to receive an appointment more quickly. The
with partners and to co-ordinate a program of initiative was designed to reduce attendance at A
interventions that, collectively, aimed to reduce & E by NHS 111 directly booking an appoint-
the pressures upon the UEC system. Examples ment with the patient’s GP for the next day, thus
from an English Sustainable Transformation reducing uncertainty for patients when they will
Partnership (STP) included: be seen by a doctor.
The multiplicity of stakeholders, IT systems
• Using quality improvement methods when and independent processes are complicated. The
supporting A & E departments to improve GP practices, 111 and NHS GP out of hours ser-
patient flow within a hospital. vices are all managed separately, have different
• Integrating and analysing data from an IT systems and different approaches to manag-
Ambulance Service, 111 and an NHS out of ing their appointments. A cause and effect rela-
hours service provider to re-design care tionship can be hypothesised, and the outcome is
12 Sustainable Hospital Transformation and Beyond 117

potentially knowable. However, it is not entirely to the combined effect of interventions must be
predictable as there are multiple variables that considered as a system change.
could impact upon the outcome. For example, If the Direct Booking project is ‘nested’ within
would people who contact services be prepared a wider transformation programme that covers
to wait until the next day for a GP appointment? multiple health economies across an STP foot-
Expert knowledge is required to ensure that print, then the leadership challenge moves from
different IT systems can support the changes. complicated to complex. The cause and effect
Workforce training and support is required to relationships are unlikely to be repeatable as each
ensure that that call handlers are aware of how local health economy and each STP footprint has
they can directly book into GP practices. GPs a different configuration of services with varying
will need to be satisfied that the changes are safe, levels of capacity and access thresholds. The col-
that the 111 triage process is robust and does lective impact of the transformation is likely to
not allow people to inappropriately receive a reveal emergent patterns that are unique to the
GP appointment. When implementing this proj- locality and to the STP footprint and, as a con-
ect, there are ‘known unknowns’ and therefore, sequence, interventions will need to be further
according to the Cynefin framework, this could adjusted and tested to achieve the desired results.
be categorised as a complicated project. The Unexpected consequences are more likely to
project cannot be a ‘complex’ project as there is emerge as organisations and people accessing
a proposed solution to a problem. Whilst it may services all respond differently to the multiple
not necessarily be the correct solution, there is service changes that have been introduced.
a hypothesis and a way to progress the project. Using this framework to understand the
Only when starting to deliver the project will it context of the transformation or improvement
become clear whether the assumptions were cor- challenge increases the likelihood of the trans-
rect. Of course, the model is open to interpreta- formation being sustained. This is because an
tion, but it does provide a helpful starting point. understanding of the context of the challenge
If things aren’t progressing as you would have will assist in understanding the most appropri-
liked, you can use the model to review and then ate approach to take and, furthermore, it helps to
try a different approach. define the leadership behaviours required in each
At an individual level, the Direct Booking context. It is important to note that problems
project might be complicated. However, at the move domains, so it is the job of leaders to create
same time, NHS England has been supporting the an adaptive approach and supporting systems to
transformation of Urgent and Emergency Care enable differential responses throughout the life
(UEC) services through the development of what of the project.
has been called a Consolidated Channel Shift
Model. This model aims to connect UEC services
together, so the overall system becomes more Context and Leadership Behaviours
than just the sum of its parts. This has entailed
identifying a number of separate interventions, As well as defining the context to help us under-
delivered by different organisations across a stand the transformation or challenges, Snowdon
local UEC health economy. The interventions and Boone [22] identify different leadership
were designed to shift activity away from hos- responses to apply to the different contexts.
pital based Accident and Emergency centres to This is helpful to leaders as it clearly defines
the most appropriate setting of care. The model how to respond to each context. When we first
is underpinned by a belief that there is no single came across this framework, we could see
intervention or activity that will ease the pressure why the broad brush, eye watering statistics of
on UEC services and it is the combined effect of change efforts fail. Inevitably, any organisation
several interventions, across different parts of the or system will have problems in all domains
system, that makes the difference. This approach at different times. This is why one approach to
118 S. Stericker and D. Lawson

transformation does not fit all situations and why useful ones in relation to achieving change are
an adaptive approach to transformation and the those that have been developed from a strong
leadership styles applied is critical to ensure the evidence base and have been applied in many
problem is addressed and is more likely to be contexts. The Behaviour Change Wheel (BCW)
sustained in the future. [25] enables leaders to design interventions and
It is easy to see why many of the transforma- achieve behaviour change in complex situations.
tion or improvement projects don’t sustain. There The BCW was developed from 19 frameworks
is an understandable tendency for senior manag- of behaviours identified in a systematic literature
ers, civil servants and policy makers to create review. It consists of three layers as indicated in
change projects that use ‘fact based manage- Fig. 12.3 below.
ment’. We feel more comfortable when we think The behaviour change wheel helps you to
we understand things (in a simple context), using understand which behaviours may need to be
a cause and effect approach. We tend to like a targeted to achieve the transformation objec-
sense of control for our actions. We also tend to tive. It uses the COM-B model of behaviour
work in an operational culture where failure is change. The model explains there are three
perceived to be exactly that, a failure rather an different behavioural elements to address
opportunity to learn. Working in the complex and to achieve change, these are: Capability,
context, it is much less clear to determine what Opportunity & Motivation, as indicated in
should be done, how it should be done and how Fig. 12.4 below.
to predict the outcome or impact. A series of trial In order to achieve change, transformation
and error actions must be undertaken to try and projects should understand which behaviours to
determine the preferred course of action that will target and how they should be changed. This is
result in the desired impact. important to ensure that any behaviour change is
Our experience is that engaging staff in the sustained, and that individuals don’t revert back
definition of the problem, as well as the cre- to their previous behaviour(s).
ation and implementation of the solution is the Surrounding the three core elements in the
most effective approach to achieving sustain- hub, is a layer of nine interventions functions
able change. Again, this is an area for improve- to select, depending on the initial COM-B
ment across the NHS and public sector. Having analysis undertaken. The outer layer then iden-
evidence to define the problem and to shape the tified seven policy categories that can support
development of a solution is important, but it the delivery of these new behaviours as part of
is often not enough when aiming to sustain any the transformation program. As the context can
change. We all know that change can be difficult change depending on the stage of the project, it
for people and, as you might expect, supporting is important to note that the behaviour change
and leading change is more complex... or is it interventions may also have to change, depend-
complicated? ing on the path of the project and any unex-
pected influences.
When designing any transformation project,
 he Type of Change and How
T it is important to follow a systematic approach
to Deliver It that allows an intervention to achieve behav-
iour change to be developed. Working in this
As well as understanding the context of the prob- way will mean a higher likelihood of the new
lem that you are trying to solve, it is important behaviour happening and being sustained. This
to understand the barriers to behaviour change. is the value of using a framework like this, as it
The change strategy must address barriers to helps identify the intervention to use to achieve
behaviour change, otherwise it is unlikely that the greatest chance of achieving behaviour
the change will be achieved or sustained [24]. change.
There are many behaviour change theories which The COM-B model of behaviour change
we are not discussing in this chapter, but the most helps you further understand the nature of
12 Sustainable Hospital Transformation and Beyond 119

Sources of behaviour Env

ir
es Soc onme
Intervention functions idelin ial
pla ntal
Gu Educati
nn /
ing
ns on
ictio
Policy categories
estr
R

Pe
O

rsu

Co arketing
s

rin l
uctu ta
sure

g
Y

as
restr nmen

PP

mm
ion

M
IT

OR
BIL
Fiscal mea

Ph
o

unication/
Envir

l
cia

TUN
ys
CAPA

ica

So

ti v i s a ti o n
l

ITY
Psychological Physical
M o d e ll

Incen
Re
ic
at

fle
m
to

ctiv
in g

Au

io n
MOT
IV A TI O N
Re

rc
e

on
En

ab
le Co
gu

ati
me
nt
la

is l
n
ti o

Traini n g

eg
L

S ervi
c e p r o visi o n

Fig. 12.3 The behaviour change wheel [25]

Fig. 12.4 The COM-B

system—a framework for Capability
understanding behaviour
[25]

Motivation Behaviour

Opportunity

the actions to be taken to achieve behaviour and be motivated to perform the target behav-
change. The model suggests that for any behav- iour more than any other behaviour. Having the
iour to occur an individual must have the physi- physical ability and stamina to ride a bicycle
cal and psychological capability to perform the is an example of the capability to perform.
behaviour, the social and physical opportunity Understanding the factors that form part of
120 S. Stericker and D. Lawson

behaviours is important because it helps define transformation: understanding context, system

which behaviours, or factors influencing behav- thinking, collaboration and facilitating behav-
iour lie within the person (e.g. the capability to iour change. We have described some tools that
ride a bicycle) and which lie outside the indi- can help navigate what is often very confusing
vidual (e.g. availability of cycle paths). territory in an informed and structured way. The
The outer ring of the behaviour change wheel key points that we would like to highlight are:
identifies the range of interventions that could
be used as potential levers of change. Table 12.1 1. Leadership can and should come from any-
links between the components of the COM-B body, not only those in formal positions of
model of behaviour and the intervention func- authority.
tions in the Behaviour Change Wheel that are • To ensure transformation is sustained,
required to support change [25]. there must be a good number of advocates
Different interventions can be chosen capable of adapting to change, maintaining
depending on the impact required. As projects momentum, ensuring delivery and evaluat-
can change in their nature, from complex to ing impact.
complicated for example, so too can the inter- 2. Creating structures and mechanisms that
ventions required to sustain the desired change facilitate more collaborative and integrated
in behaviour. working.
It is important to acknowledge the dynamic • Build a collaborative infrastructure that
relationship that exists between the context of encourage collaboration, example genu-
the change that is taking place and the barriers inely shared vision, values and goals and
and opportunities presented by cross-boundary outcomes are really important to help indi-
working. Focussing on relationships and com- viduals understand that sustainability is not
munication is important, particularly when just about the success of leaders’ individual
working in a complex system. Understanding areas of responsibility
the barriers to behaviour change is essential, 3. Don’t underestimate the influence of context
as is recognising that whilst rules, protocols, and environment upon the sustainable trans-
directives or performance targets have their formation of services
place in achieving a change in behaviour, they 4. Work across systems for transformation to be
are not the critical tools that we often believe sustainable
them to be. This is important for those leading • No single organisation or department ‘is an
change programs of this nature; the importance island’
of modelling system leadership behaviours can- 5. Understand the behavioural barriers and
not be underestimated. enablers to sustainability and focus effort and
energy on these right from the beginning.
6. Working across complex systems requires the
Conclusion and Key Messages testing of multiple approaches
• Systematically implement quality improve-
Defining sustainability is multi-faceted and ment methods, learn from ‘failed’ approaches
can mean different things to different people. and allow success to emerge.
People will behave differently depending upon 7. The ability to create and maintain construc-
their roles as, for example, a finance director, tive, effective relationships underpins all the
a patient, a clinician or an environmentalist. above points.
This chapter has focussed on four key areas for • Without positive relationships, achieving
NHS leaders seeking to undertake sustainable everything else is so much harder.
 12

Table 12.1 Linking the COM-B model to the Behaviour Change Wheel
Intervention Function
COM B component education Persuasion Incentivisation Coercion Training Restriction Environmental restructuring Modelling Enablement
Sustainable Hospital Transformation and Beyond

Physical capability X X
Psychological capability X X X
Physical opportunity X X X X
Social opportunity X X X X
Automatic motivation X X X X X X X
Reflective motivation X X X X
121
122 S. Stericker and D. Lawson

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 Part VII
Overcoming the Challenge
 The National Health
Service in the UK 13
Andrew Cash

 he 1948 National Health Service

T  ecommitting to the NHS:
R
(NHS): ‘In Place of Fear’ Why Do We Do It?

Seventy years ago almost to the day that I write To most people in England the creation of the
this, if you were living in England, a leaflet would NHS is considered one of the proudest achieve-
have come through your letterbox promising you ments of modern society representing fairness
the new National Health Service. And in beauti- and equity, held dear by all. Yet an underlying
fully clear prose it states: paranoia about the NHS remains. About once a
decade in the subsequent years since its creation
The new National Health Service begins on 5 July in 1948 we have as a country decided whether to
1948. What it is, how do you get it? recommit to that conception of a national health
service. Indeed it is pretty easy to forget that the
The leaflet says ‘it will provide you with all health service was born at a time of great eco-
medical, dental and nursing care, everyone rich nomic austerity, in the post-war period when
or poor, man, woman or child can use it or any there was no great reason for thinking, other than
part of it. There are no charges except for a few a great spirit of optimism, that the economic
special items, there are no insurance qualifica- wherewith-all would be there to support this huge
tions. But it is not a charity. You are all paying for endeavour.
it. Mainly as tax payers. And it will relieve your Nye Bevan who, of course, founded the NHS
money worries in times of illness’ [1]. in 1948 said ‘this is the biggest single experiment
The National Health Service (NHS) was the in social service that the world has ever seen’ [2].
first universal healthcare system developed after He also reminded everybody at the tenth anni-
the Second World War and was founded ‘in place versary of the NHS in 1958 that one of the great
of fear’. After the trauma of the war years, people difficulties in 1948 was that mass radiography was
demanded a new set of arrangements across a num- just beginning to detect early tuberculosis (TB)
ber of public services and the NHS was designed to so there was a huge expansion required for TB
provide essentially free care, at the point of need, beds and treatment. Thirty two thousand beds
irrespective of age, health, race, religion, social sta- in the NHS were occupied by people with TB
tus or the ability to pay—from ‘cradle to the grave’. on the day it was founded. And one of the main
reasons why we had a particular problem with
the beds was that we could not recruit enough
A. Cash (*) nurses. Bevan said at the time ‘they were so inad-
Sheffield Teaching Hospitals NHS Foundation Trust,
Sheffield, UK equately paid and the conditions were so bad that

© Springer Nature Switzerland AG 2019 125

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6_13
126 A. Cash

they could not recruit enough nurses in sufficient or different national policy changes in leadership
numbers, indeed’ he said ‘I myself had to take from competition to collaboration. One thing
the unusual step of intervening in negotiations to is clear, this country has a rich track record of
secure an increase in the wages for nurses’ [3]. success.
Of course the inception of the NHS was bit- On science and technology alone, picture a
terly opposed by many people but despite that country that had made a global impact on medi-
context, despite the capacity shortages, the NHS cal and health care science. A country that had
came into being and is now the most treasured invented a vaccination for smallpox, that discov-
institution in our country. So it is very heartening ered the first antibiotics, performed the first stem
to hear the Prime Minister, Theresa May, just a cell transplant and invented in-vitro fertilisation.
few weeks before the 70th birthday of the NHS, Or on medical devices, a country that had
once again, recommit her government to a multi invented the thermometer, the artificial hip, the
year funding settlement for the NHS for the next MRI and the CT scanner.
10 years. Or a country that punched well above its
So why do we keep recommitting to the NHS? weight in terms of medical research with 1%
Well, costing an average of £6.16 p per person of the worlds population but 16% of the worlds
per day, it is a tremendous economical bargain highest cited research papers. Putting all these
for the people of this country and relieves the sorts of achievements together gives you the
anxiety of not being able to afford healthcare ability to create a wonderful health and care sys-
when you need it. BUT of course it is more than tem—and all these elements exist here, in this
that—the NHS is a people business—a mixture country—and in the NHS.
of care and compassion on the one hand and So in this simple example of science and
incredible science and technology on the other. innovation, we are able to see one of the endear-
OK, it can seem large, bureaucratic and complex ing strengths of the NHS in England. That is
at times but at its most simplest, it is about two the relationship between academic research and
people together, one needing help and the other clinical practice. According to the Times Higher
offering it. Education World University Rankings, England
has three of the top five worldwide universities
for clinical, pre-clinical and health subjects and
 vercoming the Challenges:
O has four universities in the top ten across all sub-
Lessons from History jects [4]. The UK is placed second for hosting the
largest number of clinical trials after the US and,
The issue we now face is will the NHS, designed in absolute terms, fourth in the world for health
70 years ago, still be fit to tackle the challenges research behind the US, Japan and Germany [5].
we face ahead? Moreover what do we need to do
to make sure the NHS is fit for purpose for the
next 5, 10, 15 and 20 years? The New Challenges
History tells us that the world of healthcare is
constantly evolving around that basic construct Living Longer
of care and compassion and the person receiving
treatment and the person giving it. Science and When the NHS was set up in 1948 the average
technology is advancing. People are finding bet- life expectancy of a male was just over 65 years
ter ways of doing things. Whether it is in the field and slightly more for females. Half the male pop-
of information technology, the electronic patient ulation was dead by retirement age. Now it is just
record or artificial intelligence or in the way we over 82 years for males and slightly more for
manage buildings and services. Or in new and females. Our population is very different. We
innovative approaches to workforce development have an increasingly ageing population with
13 The National Health Service in the UK 127

people regularly living into their 80s and 90s. Integrating Health and Care
And there is a spectrum of health—some people
are hugely active, others require help from time Both the health and social care sectors are com-
to time at home. At the other end of the spectrum pletely interdependent with both sectors facing
are those that require considerable intervention similar demographic and population challenges.
and support. Many people receiving care and treatment in the
health sector are very often experiencing a ‘social
care ‘crisis but have ended up in the health world
Changing Expectations and visa versa.

People are far better informed about their health,

their own conditions, treatment and care needs. Changing Socio-Economic
More and more carers look after and support Environment
loved ones, and more and more people need to be
supported in developing the knowledge, skills Recognising the social determinants of health—
and confidence to manage their own conditions choice, education, your job, housing etc.—and
and to care for others. Increasingly people want doing something about them, have long been rec-
to stay active and be prescribed exercise as a way ognised as the ‘holy grail’ to improving health
forward. inequalities and improving health outcomes for
everyone, not just the few. The social and politi-
cal leadership required to tackle these thorny
Shortages in the Workforce issues over a lengthier period of time than just the
normal 5 year government cycle is the key.
Developing a sustainable healthcare workforce is Changing the language of health from ‘illness’ to
the key foundation stone required for a successful ‘prevention ‘requires as a starter a change in long
health and care system and is integral to the qual- term economic resource allocation.
ity and safety of the service provided, particu-
larly in the light of Brexit and an uncertain future.
More people want flexible careers, reflecting  vercoming the Challenges:
O
generational expectations and recognising this in the New NHS Leadership Task
the way we attract, recruit and retain staff in the
future is the number one challenge we face. So if Nye Bevan were here today and starting the
NHS anew to overcome these challenges, what
would he do?
Technology and Innovation

Predicting how health and care will change in the  eading Through Organising Services
L
next 5 years, let alone 20, in the face of techno- Around Individuals
logical change and innovation is exciting but
tricky to assess. What we do know is ready access Firstly, we need to acknowledge that whilst it is
to information and genomic medicine, for exam- great that we are living longer, we need to under-
ple, will radically shape and change how we stand that many more of us will develop multiple
deliver services in the future. We will see the long term conditions (stroke, diabetes, heart dis-
growth of precision medicine, robotics and por- ease etc). Here are some key facts—11.6 million
table digital diagnostic devices changing how people in England are aged 65 and over, an
patients, carers and staff use and access services increase of 21% in a decade whilst 1.5 million are
in the future. aged 85 or over, an increase of 31% over the same
128 A. Cash

period. 3.8 million people live with ­diabetes, 2.5 ideally with no neighbourhood being bigger than
million have a cancer diagnosis and one million 30,000 to 50,000 population.
additional people will have dementia by 2021.
Leaders need to build services and care around
individuals not the other way around as has been A New Deal for the Workforce
the NHS pattern of delivery in the past [6].
Fourthly, we need leadership to tackle the starkly
different expectations and motivations of the
Integrating Health and Care Services three generations currently working in the
NHS. We need to tackle the emerging workforce
Secondly, we need to back the leadership of the crisis in primary care by building up the tripartite
newly formed Sustainability and Transformation staffing structure of care workers, nurses and
Partnerships across the country and as they therapists undertaking extended roles and general
mature, the new Integrated Care Systems (ICS’s). medical practitioners. And finally, as the world
Each ICS covering a geographical population around us changes ever more quickly through
footprint ideally of 1.5 million people or above technological change and lifestyle choices, we
needs to get its constituent hospitals, care organ- need an employment offer that remains modern
isations, social service sectors, ambulance ser- and attractive to the new style NHS worker of the
vices, clinical commissioning groups, primary future [6].
care federations, voluntary and third sector
organisations to work together. This is so that
they can improve health inequalities for the pop-  eadership and Promotion of Mental
L
ulation, to provide equality of access to high Health Services
quality services for all residents and to achieve
the best value for money outcomes both clini- Fifthly, we need a new approach to the leadership
cally and service wise for the populations they of mental health services. We need to be moving
serve. from quantitative targets to deep meaningful out-
come based objectives in this area of care. There
is a particular need for leadership talent to be
Leadership at Neighbourhood Level brought to bear on the current unmet mental
health needs of young people and to tackle the
Thirdly, we need leadership at primary care double epidemic that our children face of child-
level—we need to wrap a range of services hood obesity and of addressing these mental
around individual patients—therapists, nurses, health problems.
care staff, general practitioners—making it as
easy as possible to navigate the system. We need
to keep people as independent as possible for as Long Term Planning
long as possible—ideally in their own homes if
that is what they would want. We need to support Finally, we need leadership that provides a
people and staff with technology that allows a 10 year long term plan for health and care ser-
social worker to talk with a hospital ward clerk, vices in this country which is reviewed regularly
and a practice nurse to talk with a cancer special- but is not subject to the short term whims of poli-
ist. Above all, we need to adopt the mantra that ticians. The importance of having long term
leadership is as close to the patient as it can be, objectives such as ‘every person aged 18–24 years
and only things that cannot be organised individ- in employment, education or training ‘within a
ually for a patient should be done at a practice geographical area should be as important as min-
level, or if not there at a neighbourhood level, imising waiting times for treatment. Of course,
13 The National Health Service in the UK 129

any plan needs to be led and delivered by The NHS belongs to the people. It is there to
improve our health and well-being, supporting us
­visionary leaders who need some security of ten- to keep mentally and physically well, to get better
ure in the post to have a fighting chance of when we are ill and, when we cannot fully recover,
success. to stay as well as we can to the end of our lives. It
works at the limits of science-bringing the highest
levels of human knowledge and skill to save lives
and improve health. It touches our lives at times of
Summary basic need, when human care and compassion are
what matter most [8].
The Independent Commonwealth Fund, based in
the US, has ranked the NHS as the top health sys-
tem performer across 11 countries [7]. The NHS References
came first in quality, efficiency and cost effective-
ness, and came second and third respectively for 1. ‘The New National Health Service’ prepared by the
Central Office of Information for the Ministry of
the timeliness and equity of care. Not a bad Health. 1948.
record, and one that bodes well for the leadership 2. Aneuran Bevan; 5 July 1948.
of the Service tackling the challenges that lie 3. Aneuran Bevan. NHS debate 1958 House of
ahead—living longer, changing expectations, Commons 30 July.
4. Times Higher Education. World university rankings.
workforce shortages, technology and innovation, THE; 2015.
integrating health and care and the changing 5. All-Party Parliamentary Group on Global Health. The
socio-economic environment. UK’s contribution to health globally: benefitting the
But finally I am sure Nye Bevan would say, country and the world. APPG-GH; 2015.
6. Facing the facts, shaping the future. A draft health and
if he were alive today, none of this matters a care workforce strategy for England to 2027. Health
jot unless you go back to that simple construct Education England.
between the giver and receiver of care—and the 7. Commonwealth Fund. Mirror on the wall: how
care and compassion that goes with it, that is the the performance of the US healthcare system per-
forms internationally − 2014 update. New York:
very essence of our NHS and captured so well in Commonwealth Fund; 2014.
the NHS Constitution as follows: 8. NHS constitution for England. 8 March 2012.
 Index

A Complementary and alternative medicine

Accountability, 35, 46 (CAM), 53, 55
Accountable care organisations (ACOs), 108 Conflicts of interests, 90
Accreditation, 4, 35, 82 Consolidated governance framework, 82
mechanisms, 82 Context and leadership behaviours, 117, 118
of health service, 91–92 Corporate and Financial Governance, 83
Affordable Care Act, 17 Cynefin Framework, 115
Ageing population, 126
Alternative health approaches, 53, 54
Artificial intelligence, 126 D
ASHE guidelines, 4 Directors code of conduct, 89, 90
Ashford and St Peter’s Hospitals NHS Directors’ ethical and legal
Foundation Trust, 28 obligations, 89, 90
culture of improvement, 28
monitor, 28, 29
sharing and learning, 29, 30 E
Audit Committee, 86, 87 Economical bargain, NHS, 126
Effective information systems, 47
Electronic patient record, 126
B Environment and context, 115
Behaviour change strategy, 118, 120 chaotic context, 116
Behaviour Change Wheel (BCW), 119, 120 complex context, 115
Beveridge model, 15, 16 complicated context, 115
Biomedical monolithic worldview, 52 simple context, 115
Biomedicine, 52, 55 External regulatory and monitoring, 91, 92
Bismarck model, 16
Board effectiveness and evaluation, 89
F
Finance Committee, 87, 88
C Financial accounts, 83
Care Quality Commission (CQC), 24, 26 Friends and Family Test (FFT), 10
rating, 24, 25
services, 24
Chief Executive Officer (CEO) of health G
service, 90 General taxation model, 15, 16
Chief Financial Officer (CFO), 91 Global healthcare
Clinical governance, 82 challenges
Collaboration and working in partnership, 113–114 accessibility and rationalisation of healthcare
Collaboration outside organisation, 113, 114 services, 9
Collaboration within organisation, 113 cost control, 8
COM-B model of behaviour change, 118–120 human resources and workforce, 8, 9
COM-B model to the Behaviour Change Wheel, 121 medical education, 9
Community Advisory Committee, 88, 89 patient centric healthcare, 10

© Springer Nature Switzerland AG 2019 131

D. Burke et al. (eds.), Hospital Transformation, https://doi.org/10.1007/978-3-030-15448-6
132 Index

Global healthcare (cont.) functions, 84, 85

population demographics and disease membership, 85
pattern, 7, 8 obligations, 85
quality and outcome measures, 9–10 selection, 85
opportunities Health service Directors, 90
careers, 11 Health service executive, delegations to, 89
investment, 10, 11 Health Service Governance Framework
research, 11 Checklist, 92, 93
teaching and training, 11 Health service Translation Precinct (MHTP), 93
regulatory requirement Health service’s Executive Committee, 90, 91
accreditation, 4 Health system, 59
evidence based medicine and regulation, 5 Heating, ventilation and air conditioning (HVAC), 4
licensing, 4 Hegemonic process, 60
medical regulatory authority, 4, 5 High reliability organizations (HROs), 44
model of healthcare delivery, 3 Hospital transformation, 75, 78–79, 95, 99
patient safety, 3, 4 case study, 100
quality assurance and regulation, 5 communication and engagement, 96
structural regulations, 4 company culture, 99
delivery of patient care
data insights, 97
H outcomes oriented, 97
Harmony ideology, 63 patient focused, 97
Health and social care, 116 root cause analysis, 97
Health and social care sectors, 127 external stakeholders, 96
Health Building Notes (HBN), 4 finance, 98
Healthcare model cost effective, 97
Beveridge Model, 15, 16 financial priorities, 97
Bismarck Model, 16 leadership, 96
governments, 18 management level, 97
National Health Insurance Model, 16 operational efficiency, 97
private insurance and out of pocket model, 16–17 organisational culture, 96
U.S.A., 17, 18 organisational Level, 96
Health care provision, NHS, 115 participation, 99
Healthcare regulation, 36 performance, 98
Healthcare system, 36, 44, 112 performance management and accountability
Ashford and St Peter’s Hospitals NHS Foundation framework, 96
Trust, 28–30 positive reinforcement, 99
CQC, 24 quality and safety, 98
rating, 24, 25 sense of urgency, 98
services, 24 short term gains, 99
culture, 26–28 transformation group, 98
effective, 23 transparency, 96
high performing organisation, 25 workforce, 96
high quality, 23 Hospitals fail
leadership, 25, 26 culture, 45, 46
responsiveness, 26 information gathering and management
safe, 23 system, 47, 48
sheffield teaching hospitals, 28 leadership, 44, 45
Tees Esk and Wear Valley, 28 planning processes, 48
Health crisis, 51, 54–55 vision, 46, 47
Health reforms, political economy, in Chile Hyperdiscipline, 52
in England, 61
hegemonic process, 60
in Latin America, 59, 61 I
social protection systems, 60 Illness of health care systems
Welfare State (see Welfare State) alternative and natural approaches, 54
Health service Board, 83–85 epistemological Issues, 51, 52
Board chair, 85 power relations and political economy, 53, 54
Board member resignation and removal, 85, 86 practical implications, 55
composition, 85 science and knowledge, 52, 53
Index 133

Improvement evaporation effect/initiative decay, 109 NHS Five Year Forward View, 107, 108
Indian Code for Hospital Builds, 4 NHS Innovation & Improvement model
Information technology (IT), 126 for sustainability, 111
Integrated care systems, 114 NHS Innovation and Improvement Agency, 109
Integrated Care Systems (ICS’s), 128 NHS trusts, 5, 10, 24
Integrating health and care services, 128 Non governmental organisations (NGO), 4, 10, 18
International health organisations, 30 Noncommunicable diseases, 8
International Health Planning Guidance, 4
International Society for Quality in Health
Care (ISQua), 35 O
International Standards Organization (ISO), 4 Obesity, 8, 52
Investing in local and national evaluation, 109 Organisational culture in NHS, 113
Out of pocket model, 16–17, 64

J
Joint Commission on Accreditation of Healthcare P
Organizations (JCAHO), 4 Patient centric healthcare, 10
Just culture, 46 Patient safety, 75, 77
Place-based transformation, 112
Primary care services, 8
K Private interests, declaration of, 90
Keynesian economic policy, 61 Privatization process, 67, 68
Professional cultures, 112
Public health care system, 51, 65
L Public health service, 82
Law of Preventive Medicine, 62
Leadership and promotion of mental health
services, 128 Q
Leadership at primary care level, 128 Quality and system improvement, 112
Learning strategies and methods, 113 Quality assurance model, 37
Legal obligations, 83 Quality Committee, 87
Long term plan for health and care services, 128 Quality improvement (QI), 45
Quality improvement system (QIS), 28

M
Mechanical analogy, 52 R
Medical education, 9 Really responsive regulation, 36
Medical leadership Remuneration Committee, 87
medical director in failing hospital Responsive regulation, 36
transformation, 78–79 Risk-based regulation, 36
medical manager, 73 Risk management and compliance, 83
non-clinical managers, 73 Root cause analysis, 97
project management triangle, 74
strategic objectives hospitals, 75–78
cost, quality and safety, 76 S
finance, delivery and experience, 75 Safety assurance, 39
low risk hospital, 77 Safety regulatory system, 39
patient safety landscape, 77 Science and technology, 126
turnaround process, 74–75 Secondary care system, 8
Self Assessment Health Checklist for Healthcare
Organisations, 100–103
N Semi-autonomous local health systems, 65
National Health Insurance Model, 16 Social care crisis, 127
National Health Service (NHS), 15, 125 Social consciousness, 67
National messaging, 109 Social determinants of health-choice, 127
National Reporting and Learning System Social market economy, 68
(NRLS), 30, 78 Social policy, 65
Neo-liberal market model, 64 Social reforms, 59
Neo-liberal reforms, 67 Social security, 54, 62, 67
NGO, see Non governmental organisations (NGO) Social Security Service (SSS), 62
134 Index

Social welfare, 61 V
Socio-economic environment, 127 Values based healthcare delivery (VBHCD), 29
Sustainability and transformation partnerships, 128
Sustainability in acute hospitals, 107
Sustainability in NHS acute hospital care, 109, 110 W
Sustainable Development Unit (SDU), 109 Welfare State, 61
Sustainable health and social care services, 108 development of, 62–64
Sustainable healthcare workforce, 127 Chilean socio-medical reality, 62
Sustainable Transformation Partnership (STP), 116 health legislation and reform, 62
System leadership, 116, 120 incorporate public institutions, 63
System thinking, 115, 120 National Health Service, 62
neo-liberal models, 64
primary and preventive care clinics
T and laboratories, 63
Technological change and innovation, 127 process-oriented, 63
Tees Esk and Wear Valley, 28 rule of social progress, 62
Tertiary care system, 8 semi-public insurance system, 63
Transformation process, 107 Unidad Popular, 63, 64
Transformational change process, 98 end and new market model, 64–68
Transforming hospital accreditation cold market model or a state model, 68
clinical outcome measures, 38 financial anarchy, 67
data driven improvement, 35–36 mixed system, 68
implications of new model, 39 neo-liberal reforms, 67
patient experience measures, 38 private pre-paid health institutions, 65
problems with current hospital accreditation privatization process, 67
systems, 36–38 public health care system, 65
really responsive, 38 semi-autonomous local health systems, 65
safety assurance, 39 social concern into individual
staff members’ experience measures, 38 concern, 67
Turnaround of failing hospitals, 100 social consciousness, 67
social policy, 65
social spending program, 64
U Weltanschauung (cosmovision), 52
Urgent and Emergency Care (UEC) services, 117 Workforce crisis in primary care, 128