healthcare organisations struggling to improve quality

Identifying characteristics associated with struggling healthcare organisations may help inform improvement.

The article published in BMJ Quality and Safety in july 2018 is a systematic reveiw of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined "by below-average performance in patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators)".

33 articles from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis.

Five domains characterised struggling healthcare organisations: 

1. Poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), 
2. Inadequate infrastructure (limited quality improvement, staffing, information technology or resources), 
3. Lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), 
4. System shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), 
5. Dysfunctional external relations with other hospitals, stakeholders, or governing bodies.

Many characteristics shared by struggling organisations were counter to characteristics associated with high-performing organisations. For example, while disconnected leaders and non-collaborative environments were frequently found in struggling organisations, engaged leadership and a collaborative organisational culture are associated with high performance. Furthermore, a ‘flat’ or team-based approach to problems is often associated with high performance, whereas they found hierarchical culture in struggling organisations.

System shocks’ was a domain unique to struggling organisations. Although not all change necessarily causes disruption, being unprepared or unrealistic about the effort required can demotivate and anger staff. To prevent disastrous consequences, shocks must be anticipated and addressed. When shocks cannot be anticipated, leaders may directly address shocks to reduce negative consequences and potentially create positive change.

The study has important implications. The findings suggest that health systems preparing for large-scale organisational change should adequately prepare in order to prevent system shocks, which, counterintuitively, may impede change. Also the study underscores the importance of context, organisational climate and related factors in determining hospital performance. 

Open access article: Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies (2019)

photographer: Leopoldo Pomés (1931-2019). Foto Colectània 
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