2009年12月9日 星期三

AGENDA MANAGEMENT AND KNOWLEDGE TRANSFER

AGENDA MANAGEMENT AND KNOWLEDGE TRANSFER: EVIDENCE FROM A STUDY OF THE INTRODUCTION OF ROOT CAUSE ANALYSIS OF MEDICAL ACCIDENTS IN TWO AUSTRALIAN PUBLIC HEALTH SYSTEMS

Dr David Meacheam
University of New South Wales School of Business, Australian Defence Force Academy,
Northcott Drive, Campbell, ACT 2600
Email: D.Meacheam@ADFA.edu.au

The focus of this study is on the transfer of knowledge of the root cause analysis (RCA) of medical accidents into two Australian State public health care systems, those States being New South Wales (NSW) and Queensland (Qld). The study undertaken was exploratory and qualitative, relying upon analysis of semi-structured interviews and examination of documentation. Emergent issues were identified, documented and verified through reference back to interviewees. The study illustrates that differences between the States in terms of who drove the introduction of RCA and aspects of the structure of the relevant health authorities had significant effect on how knowledge re RCA was developed and applied within the two States. The role of party political processes in the shaping of how RCA has been implemented in each State is critically assessed.
Introduction:
While the generation of new knowledge, creativity and innovation are well understood at the level of individual organizations (Amabile, 1997, Amabile, Hadley and Kramer, 2002, Kanter, 1983, Kanter, 1988, Nonaka and Takeuchi, 1995), and through studies of ‘communities of practice’ (Brown and Duguid, 1991, Iverson and McPhee, 2002, Wenger, 1998, Wenger, 2000, Wenger, 2005) we know of the transfer of knowledge between individuals who share common concerns, generally related to their discipline backgrounds. However, little is known of how such innovations are developed and transferred internationally between organizations that don’t have a formal obligation to enable such development and transfer of knowledge and lack a strong commercial reason for doing so.
This study is exploratory, seeking to identify the key enablers of the transfer of knowledge between the US Veteran Affairs Commission, in particular, where healthcare RCA of medical accidents was developed, to NSW and Queensland.
Background:
The study was undertaken in tandem with the work of colleagues at Warwick University examining the introduction of RCA of medical accidents in the USA and United Kingdom.
Within Australia the provision of public health services is primarily the concern of each of the separate eight States and Territories. Attempts at centralised (Commonwealth of Australia) control of health are relatively weak. A Commonwealth apparatus exists that has encouraged the adoption of RCA for investigation of medical accidents, but the transfer of knowledge and implementation of State systems have remained as the concerns of individual States.
In the instance of Australia, a widespread but low level of readiness to address medical accident problems came from 1995, which saw publication of a report by Wilson and others relating to quality in healthcare. That report found that 16.3-16.5% of patients experience some sort of adverse event when admitted to Australian hospitals (Wilson, Runciman, Gibberd, Harrison, Newby and Hamilton, 1995). A later publication expanded on these findings (Wilson, Gibberd, Harrison and Hamilton, 1999). While the accuracy of that study has been questioned, in particular the extent of the problems identified, the effect of the report was to push patient safety into the attention of the healthcare community.
Reliance upon RCA techniques for the investigation and remedy of medical accidents in Australia is relatively new, beginning from about 2001 in NSW, and 2003 in Queensland. The use of RCA for medical accident investigation is now in place for all Australian States. In most States the use of the technique is supported by legislation to allow privilege in proceedings and encourage full and open disclosure by health professionals. In NSW the RCA process is also required in private health care facilities; this is yet to happen in Queensland.
In an Australian context, the term ‘medical’ is commonly construed as relating to doctors, with ‘nursing’ concerns being the other prominent matter. In the following paper the term ‘medical accidents’ is used to refer to failures across the whole ambit of health care providers and settings.
Method:
Semi-structured interviews were applied in an effort to both generate comparability between responses in Australia relative to responses in the USA and UK and to identify emerging issues in relation to the transfer of RCA knowledge. The analysis of the Australian experience of RCA relative to that of the UK and USA will be the subject of a future academic paper.
With reliance upon the advice of an academic on the reference group for this study, key potential interviewees were identified in the health administration systems of both the States under study. The leanness of Australian public health administration structures, plus the difficulties of arranging interviews with key interviewees meant that few interviews were conducted relative to the numbers conducted by colleagues within the USA and UK health systems.
Human research ethics approval was sought and provided by both the University of Newcastle and the relevant public health authority.
In NSW 4 people were interviewed, 3 at the senior State-wide health administration level, the 4th at the senior level within the clinical governance unit of one of the local health authorities. That authority was one of the first to implement RCA of medical accidents. In Queensland three people were interviewed, all were senior members of the staff of the Queensland Patient Safety Centre. Owing to both time constraints, and limits to the ambit of the human research ethics consent given for this research, it was not possible to interview anyone at the clinical governance level within the Queensland health system. RCA and general medical accident documentation was examined from both States.
All interviews were recorded, and transcripts made of the interviews. These transcripts were then subjected to analysis, with reliance upon Nvivo software. Common and emergent themes were identified and documented. The draft findings of the interviews were confirmed by relay of draft papers back to interviewees. All interviewees were given an opportunity to read and correct the drafts of this paper.
Findings:
In the instance of NSW, the introduction and on-going development of RCA within the health system has been driven by health bureaucrats and training and development specialists, rather than health professionals. Public health care provision in NSW for the past decade has been marked by a succession of crises, generally precipitated by shortages of funding, failures in planning and perceived deficiencies in party political management.
The situation in Qld over the past decade or so has been similar, with a regional hospital being near closed for some time, as a result of staff shortages, and the very high profile case of Dr Jayant Patel, accused of negligence in his care of a range of patients at Bundaberg Public Hospital, a matter referred to further below. In aggregate however the Qld public health system can be seen as performing better in the past decade that has been the case in NSW.
One of the Queensland interviewees, Dr John Wakefield outlined what he saw as the need for a ‘burning deck’ before any health administration was likely to consider implementing RCA of medical accidents. In NSW that ‘burning deck’ came with a series of accidents in a particular regional health authority, where whistle-blowing staff (primarily nurses), made a major issue of medical accidents in local hospitals in the period leading up to a NSW State election. In the ensuing debate in the public media, State political leaders sought to allocate blame for what had been systemic public health system failures. Key people within the NSW health bureaucracy grasped the need to set in place a process that focussed on the problem-solving aspect of RCA of accidents, rather than the allocation of blame. In interview, a Queensland health bureaucrat reported that when he was visiting and learning the basics of the RCA system within NSW, a colleague within that system argued that it wouldn’t succeed within Queensland until some crisis came into play that forced the agenda for change. In the words of that interviewee, there needed to be a ‘burning deck’ before anything would happen in Queensland in relation to RCA.
That crisis came to Queensland when a doctor at Bundaberg Public Hospital was accused of presiding over a series of poor surgical outcomes. This was the opportunity Dr Wakefield needed to fast-track the development of the Queensland RCA and a more general health-care quality system. Capitalising on the lessons learned from NSW’s work, Dr Wakefield persuaded the Queensland State Minister for Health, and other key political players, to agree to the establishment of a comprehensive health care quality system.
Rather than the blame-free emphasis of NSW, the recurrent theme within Queensland is upon a ‘just’ process. The term ‘just’ implies a legalistic approach. This may be attributed to the presence within the Patient Safety Centre of a senior Queensland bureaucrat having both a medical and legal education. It could also reflect a preference for procedural fairness and consistency and efforts to ensure transparency.
It is notable that within NSW one senior interviewee expressed a view that RCA of medical accidents was embraced because of a pattern of adoption of techniques developed by the US Institute for Healthcare Improvement, (IHI). In the words of that interviewee, there was a pattern of the NSW health bureaucracy adopting IHI innovations ‘wholis bolis, without consideration of its local appropriateness, (though in this instance, its adoption was probably appropriate, given its uptake over the same period in the UK). The US Veterans Affairs Administration and National Centre for Patient Safety (NCPS), and in particular Dr Jim Bagian of the NCPS were highly influential also in the introduction of RCA, as they were also in Queensland and other Australian States. The pattern of their involvement, both in NSW and Queensland was to support local implementation of RCA initiatives. It is notable however that in Queensland there is a strong consistency of RCA practice, albeit adapted to the particular circumstances of the State.
In NSW the localisation has pervaded even the local area health administrative levels, so that there are considerable levels of inconsistency of both the numbers of RCA investigations undertaken, and the process differs between the 11 separate public health administrations. In NSW the training for RCA has proceeded on a ‘train the trainer’ system, with key individuals being centrally trained, with trainees then being responsible for further training at the area health level. Within Queensland all staff are educated centrally, and there is a strong insistence upon uniformity of practice of RCAs.
The importance of the role of the key exponents of RCA, Dr Jim Bagian, can scarcely be over-stated. Bagian is both an engineer and a medical practitioner. Prior to his work promoting RCA within the US health care system, Bagian worked as an astronaut for NASA. His effectiveness seems to spring from both his capacity to form effective relationships with key individuals, and this very persuasive use of stories. As reported by interviewees, Bagian has a particular skill in addressing through stories the deep cultural and behavioural patterns that underlie many medial accidents. The generally poor standards of hand washing by health professionals are a ready instance of such cultural and behavioural patterns.
In both States the focus is upon finding procedural and systemic factors that have contributed to medical accidents. In neither State is attention paid to the influence of such factors as escalating workloads for health professionals, as illustrated by the following excerpt from an interview:
DM: So you’re saying there’s a tendency towards very facile or surface investigations?
Interviewee: Yeah, and there’s always been, and was in the original training, a hesitancy to really identify the big picture issues.
In both States there is ‘an elephant in the room’. That elephant is the inadequate and worsening supply of medical professionals, in particular doctors and nurses, and the associated intensification in the workloads of staff. The average age of nurses in NSW is 45 years (Australian Institute of Health and Welfare., 2008). Even with the recent raising of the retirement age in Australia from 65 to 67 years, the next 12 years or so will likely see the supply equation looking very poor. The split in the responsibility for health care between the Federal (Commonwealth of Australia), and the States level compounds this problem. There is duplication of some health services, and accusations that State agencies seek to shift costs to the Commonwealth (through, for instance pushing patients towards general practitioner care, because GPs are Commonwealth funded), and perceived efforts by the Commonwealth for the States to take on more health service responsibility.
Discussion:
The differences in the experience of the two state health systems under study are stark. For ease of comparison, the experience of each State will be dealt with separately below.
New South Wales
People: Within NSW there has been little continuity in the involvement of key people in the RCA system, with the pioneers of that system moving to new roles. The creation of the RCA system, and the associated reporting mechanisms, a database system termed ‘Incident Information Management System’ (IIMS) seems to have been first regarded as a technical task, rather than an effort directed at changing culture or mindsets, though the evidence of the interviews is that the latter has occurred, particularly in the NSW nursing community. Key staff responsible for the setting up of the NSW Health Patient Safety and Clinical Quality Program seem to have ‘read the writing on the wall’, that their work was complete and exited NSW Health. In some instances those exiting went on to work for consultancies responsible for implementing patient safety measures in other health constituencies.
While staff in the Quality and Safety Branch of NSW Health commonly have health care backgrounds, the Director has a risk management work history.
Process: Within NSW, the system developed can be characterised as fragmented, with limited efforts to maintain uniformity of RCA between different local area health authorities. At the senior health bureaucracy level, individuals seem reluctant to be publicly identified as being responsible for patient safety. Little of the key literature discussing RCA or quality and safety in patient care carries any identification of the authorship of that documentation. Both the NSW Health and Clinical Excellence Commission websites contain information re the structures and titles of positions within the agencies concerned with RCA, but don’t identify the individuals concerned.
The emphasis has been upon the development of a blame-free process. This emphasis can be attributed to efforts by the health bureaucrats concerned to create some bulwark against the NSW State politicians who have sought to allocate blame for health system failures. As one interviewee reported:
Interviewee: “The political situation in New South Wales is pretty bad.”
The history of Health ministers within NSW over the past ten years is evidence of the instability of the political situation. In that time two ministers have resigned in disgrace (one during the preparation of this paper), another rose to become State Premier, then resigned in frustration as his party blocked attempts for change in the electric power industry. Over the past ten years, numerous Ministers, assistants and senior NSW public health officials have been forced from their jobs as ‘sacrificial lambs’ when systemic failures have occurred (ABC Premium News, 2008a, ABC Premium News, 2008b, Barnes, 2008, Central Coast Express Advocate, 2007, Margetts, 2008, Miller, 2009, Sedgman, 2004, Sikora, 2007, Skelsey, 2004).
There is also a degree of inconsistency within the NSW State system. One agency, the Quality and Safety Branch of NSW Health is responsible for the training and development of NSW Health Care staff, while a second organization, the Clinical Excellence Commission, (not directly within the NSW Health structure), sets policy and uses Quality and Safety Branch RCA and other data to identify trends in service breakdown and address systemic problems. While this simple separation of functions (and the separation of policy from execution) seems ideal, NSW interviewees reported that in practice the separation of roles wasn’t always clear, despite efforts by staff in both organizations to maintain rationality and consistency. There are a number of constraining factors, including a high churn rate of staff in key roles in both agencies, the part-time employment status of the director of the Clinical Excellence Commission and job security fears across a broad span of NSW Health departments and positions.
Outcomes: The issue of managing the patient safety agenda has been dealt with in a very different manner in each of the two States under study. Within NSW the system was developed in a defensive fashion, with the key developers maintaining a low profile in a professionally driven effort to avoid the blaming preferred by their political masters. In part this may have been because the ‘burning deck’ in NSW came before the State bureaucracy had begun to grasp how useful RCA might be in the management of health accidents and a general improvement in patient safety within the system. There has been a high turnover of staff within the key positions within the two agencies responsible for RCA work; this has exacerbated the fragmentation of RCA efforts.
Queensland
People: In stark contrast to the instance of NSW, in Queensland the system developed has been continuously managed by a key person, Dr John Wakefield. Within Queensland there is identification within public documents (websites, publications) of the key officeholders, including Dr Wakefield. His focus has been upon both the upward management of the legislative and administrative structures within which the patient safety system sits, and the downward management of the Queensland Patient Safety Centre. Dr Wakefield has also deliberately put into key patient safety roles both a nurse and a medical practitioner, in order to engage productively with the two major discipline groups responsible for reporting medical mishaps. The following excerpt from a Queensland interview illustrates the rationale for this:
Interviewee: “It’s no good having an administration officer trying to change a bunch of doctors. It’s not rocket science, but that’s what people have done…”
The same interviewee spelt out the task ahead:
Interviewee: “We have not tackled the real issue, which is moving health from a cottage industry, particularly in the medical sense, the doctor sense, to one that is more of a managed system, and there is no legitimacy of management in the context of standards.”
Process: Within Queensland there has been a continuity of senior staff in key roles, though the system is two years newer than that in NSW, it is difficult to be conclusive of this. Key individuals within Queensland have actively managed the political agenda, seizing in particular upon one key series of medical care mishaps to enable the development of the RCA system (the ‘burning deck’). Moreover, two of the key drivers of the Queensland system have been from the more powerful medical practitioner discipline. This has heightened the political clout of the Qld Patient Safety Centre, and highlights the extent to which the Patient Safety Centre is focussed on cultural change within the medical practitioner community. One of the senior Patient Safety Centre staff (a doctor) focuses on detection and correction of work by doctors that is deficient. Her work is to encourage in particular older doctors whose skills are declining to exit high-risk work. She does so not via any technical, RCA type process, but rather via moral suasion, and raising of awareness amongst the doctor community to encourage their less competent colleagues out of high risk work.
There is a strong insistence by the Patient Safety Centre that RCA’s be conducted in a wholly consistent manner across all the health authorities within the State. The Nursing Director of the Patient Safety Centre reads all reports of the most serious incidents within the Qld system, and is quick to correct deviations or oversights in the RCA process.
Outcomes: In Queensland the outcome is a highly uniform approach to the use of RCA of medical accidents. As in NSW there has been a rapid acceleration in the number of RCA’s conducted. It is probable that this increased number reflects a growing willingness to improve patient safety, and a decline in fear of the process, rather than any growth in the number of mishaps.
The findings of this research are summarised in table 1, below:

Aspect Qld NSW
People:
Accountability Focus on one organisation, the Patient Safety Centre, Brisbane. Split between the Quality and Safety Branch with NSW Health and the Clinical Excellence Commission, both in Sydney.
Leadership 3 strong, readily identifiable characters within the Patient Safety Centre, all work full-time on patient safety Identification of key characters not possible via public sources. Pioneers of RCA have all moved to other roles, mostly outside NSW Health. Clinical Excellence Commission CEO is a part-time MD. Patient Safety Branch, Director has a risk management background, including 12 years with Royal Australian Air Force.
Process:
[Tentative] rationale for invoking RCA as a method Personal influence of Bagian on Wakefield + ‘the burning deck’ (Patel at Bundaberg Hospital) ‘We commonly take on any technique developed by VA’ + ‘the burning deck’ (Campbelltown/Camden allegations)
Focus of RCA and other patient safety enquiry mechanisms A just process A blame-free process
Management Heavily centralised, strong insistence on uniformity of process across all area health levels Management is de-centralised. Conduct and frequency of RCA use reportedly varies between area health services. Database use (IIMS) is key co-ordination mechanism
Change focus Cultural shift (esp. via storytelling), tight RCA regimes Process driven, loose RCA regime
Training in RCA Heavily centralised (training and administration) at Patient Safety Centre, Brisbane. De-centralised. Quality and Safety Branch within NSW Health operate on a train-the-trainer model.
Senior level reporting relationships CEO of Patient Safety Centre (Wakefield) is member of the Queensland Health Executive Management Team [bureaucratic link] Clinical Excellence Commission Director reports directly to NSW Minister of Health [political link], NSW Health Quality and Safety Branch Director reports to the Acting Deputy Director-General of the Health System Performance Division [bureaucratic link]
Outcomes: Strong enforcement of a centralised standard of RCA investigations.
Localised standards for completion of RCA’s, considerable variance between health care management regions in terms of the number and types of investigations undertaken.
Conclusions drawn:
The following are some key, initial realisations from the research that specifically relate to the experience of the two Australian States under study:

1. Crisis: The experience of both States under study is that a ‘burning deck’ (that is, an immediate crisis) is needed before people are propelled to take effective action (Greiner, 1972, Hurst, 1995, Smart and Vertinsky, 1984). In the instance of both States, the ‘burning deck’ was real, rather than contrived (vs. the common experience in organisational life, where financial crises, in particular, can be quite readily constructed via the tweaking of organisational balance sheets). Such crisis in large health care systems are relatively common, the occurrences of crisis being driven by the size and complexity of the systems, and to some extent by cultural conditions. In the UK, systemic failures at the Bristol Infirmary was a driver of the adoption of RCA as a technique ("The Bristol Royal Infirmary Inquiry Report: Learning from Bristol," 2001, Coulter, 2002, Keogh, Spiegelhalter, Bailey, Roxburgh, Magee and Hilton, 2004, Kewell, 2006), the very origins of the RCA techniques used in health services across the US, UK and Australia have their origins in the US space program, where Jim Bagian’s work began with RCA of problems within NASA’s space program.
2. Leadership: Strong leadership is needed for the transfer of knowledge to a new setting, and for implementation of a new system (Pan, 1998, Politis, 2001, Ribiere and Sitar, 2003). Dr Jim Bagian has provided such leadership in relation to RCA of medical accidents. In Qld that leadership has emerged centrally, with three key figures addressing the political, medical practitioner and nursing constituencies. In NSW the leadership has been much more distributed, to health quality practitioners at the area health service level.
3. Storytelling: It is well established that stories and storytelling are key instruments for the effective transfer of knowledge (Boyce, 1995, Dennehy, 2001, Snowden, 1999, Snowden, 2000). A strong reliance upon the telling of stories to both catch the attention of the health care community and galvanise people toward change flows all the way from the pioneer of RCA in health care, Dr Jim Bagian, through to the implementation of the systems in both States, and as a feature of reporting of trends in the day-to-day operation of the RCA systems.
4. Centralisation: It is evident from the case of these two Australian States that centralised efforts work best if uniformity of process is needed (Miller, 1987, Miller and Friesen, 1984, Mintzberg, 1979, Mintzberg, 1981, Mintzberg, 1983). NSW interviewees expressed concern at the unreliability of process, particularly within some of the smaller and remote health care regions within the State. The de-centralisation of training in the conduct of RCA’s in NSW appears to have helped develop localised versions of the process. Within Qld the directness of training in RCA techniques at the Patient Safety Centre has built a very strong consistency of practice.
5. Power: Machiavelli wrote: “Since love and fear can hardly exist together, if we must choose between them, it is far safer to be feared than loved.” (Machiavelli and Marriott, 1958). Despite the existence within NSW of legislated guarantees for the protection of whistleblowers, the evidence is that those who speak out don’t fare well. Fear as a control mechanism seems to be dominant. The circumstances in NSW suggest that party-political fear will drive the health bureaucrats involved in transferring and implementing new routines to seek anonymity (Corey, 2004, Gibb, 1965, Lawrence, 2006, Leventhal, Singer and Jones, 1965, Rachman, 1990, Ryan and Oestreich, 1991, Zand, 1997). Within NSW another response to fear has been an emphasis on a ‘blame free’ approach to RCA’s. The emphasis upon a blame-free approach can be construed as an effort by key bureaucrats to drive fear out of the RCA process.
Implications for policy and practice
As this is work in progress, it’s not appropriate to come down with hard and fast conclusions, especially when in the longer term account needs to be made of fitting the conclusions of this study with findings from the implementation of RCA within the US and UK healthcare systems.
However, it seems evident that if the aim of the transfer of knowledge is for a replication of the most advanced processes, that enduring leadership of the change process is needed for the successful transfer of new knowledge, that key stories prepare people to accept change, then strong central control is warranted of both the learning and use of a new technique, and that party politically based fear within an organization will push bureaucrats to seek anonymity within the system.
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