Making high quality care an organisational strategy: Results of a longitudinal mixed methods study in Australian hospitals

Abstract

Significant resources are spent on monitoring and improving the quality and safety of hospital care; however, evidence suggests that this investment is achieving disproportionately limited results. Accreditation and expectations of funders have focused hospital service quality management on compliance, with an over emphasis on the ‘control’ aspect of Juran’s Quality Trilogy. This study compared the impact of the implementation of a strategic quality management system with existing compliance-focused quality management systems in a sample of Australian hospitals. Through action research, mixed methods data were tracked and compared implementation progress and outcomes between four experimental and four control hospitals from 2015 to 2017. While three years was not enough time to observe quality changes resulting from the implementation, three experimental hospitals made high quality care a strategic priority for their organisation and developed organisation-wide processes to achieve it. These hospitals demonstrated that including a strategic quality planning component in quality system design and implementation, as advocated by Juran but absent in many hospital quality systems, was a positive lever for staff commitment to delivering consistently high quality care.

Keywords

hospitals quality of care quality planning strategic quality management

Background

Hospitals aim to ensure consistently safe, high quality care, but this remains a challenge in Australia,^1–3 and around the world.^4–6 Significant resources are spent on activities to monitor and improve the quality and safety of care, achieving disproportionately limited results.^7–9 In the 1980s Juran stressed the need for a Quality Trilogy, comprising quality planning, quality improvement and quality control.¹⁰ All three aspects of the Quality Trilogy were essential for product and service quality. Juran described quality planning as a critical component of an organisation’s strategic business planning, enabling management and staff to understand and share goals for achieving the quality of the products and services essential to success.¹¹ This is consistent with findings that performance is related to clinical engagement and senior management support for quality improvement.¹² The other two components of Juran’s Quality Trilogy, control and improvement encompass compliance with standards and specifications and improvement to meet compliance requirements. Improvement also relates to monitoring, feedback and evaluation of quality goal achievement, providing feedback to staff, and facilitating action to improve identified shortcomings.¹⁰

In recent years increasing accreditation and funding requirements have skewed existing hospital quality systems towards the ‘control’ component of Juran’s Quality Trilogy, with quality improvement largely focused on achieving compliance.^13,14 Despite the acknowledged importance of strategic planning and management^15,16 few hospitals have clear strategic plans for care quality^5,17 and even where these plans exist, implementation is often ineffective.^18,19 Juran’s quality planning processes are backed by strong evidence of a positive relationship between strategic goal setting and organisational performance,²⁰ including in health care where organisational and individual goals for quality patient care are found in higher performing health services.^5,21,22 An essential aspect of Juran’s quality planning is strategy implementation through line management.^11,23 Managers must know what is required to achieve care quality and support their staff to enact their role in achieving the desired outcomes.^10,24 This approach is not common in health care, with the challenges of implementing effective systems to achieve high quality care routinely discussed in the literature.^13,18,19 In summary, there is limited evidence on the impact of strategic quality management systems in hospitals, largely as a result of the lack of successful implementation of such systems. We could only find one study from Iran²⁵ outlining the positive effective of the implementation of a strategic collaborative quality management system in healthcare. However, this study provided only descriptive analysis of changes in quality management performance pre and post-implementation.

Although theory development in strategic planning and management has been expanding since the 1980s, there is little practical evidence of the impact of implementation of strategic hospital quality management systems. This led to the research question: Is the implementation of a strategic quality management system (SQMS), drawing on the Juran Quality Trilogy with a focus on the ‘planning’ component, associated with better quality care than that which currently exists within compliance-focused quality management systems?

Methods

Eight hospitals in one state in Australia volunteered to participate in a longitudinal three-year mixed method study, tracking the implementation and impact of their quality systems. A convenience sample of four experimental hospitals agreed to implement the SQMS, comprising a large multi-campus metropolitan hospital, one regional public hospital, a regional private hospital and a rural district hospital. The control sample included one large multi-campus metropolitan hospital, a metropolitan single campus hospital and a regional and a rural public hospital. The sample was restricted to one state, as while there are overarching national health policy directions in Australia, the states have relative independence in the management of hospitals to achieve national goals.

The SQMS intervention

At the commencement of the research, all participating hospitals had compliance-focused quality management systems in place as required for accreditation and funding purposes. The Board and executive of the four experimental hospitals agreed to implement the SQMS over the course of the three-year study. The SQMS was based on previous study in this area²⁵ and comprised:

Quality planning:

Define high quality care and develop corresponding strategic goals, with the involvement of staff and consumers.

Translate the strategic goals to operational point of care actions to guide everyday staff behaviours and decision making.

Implementation:

3. Strengthen clinical governance systems, comprising systems to support leadership and culture; consumer partnerships; people and practice; and to support line managers and staff to define and actively pursue the quality goals and actions for every consumer, commensurate with their role.

Monitoring and improvement:

4. Develop measures to track achievement of the quality goals.

5. Monitor progress and respond with action to further drive progress with goal achievement.²⁶

Qualitative methods

The qualitative methods have been described in detail, with a summary provided here. Focus groups were chosen to obtain the greatest input throughout the hospitals on the perceptions of staff both designing and using the quality management systems. The focus groups were scheduled twice a year, with a minimum of four focus groups held at a time with groups of similar staff in the smaller hospitals, and greater numbers of focus groups in the larger hospitals to limit the number of participants to allow all participants to participate fully. Over 900 hospital managers, clinical staff and board members in the eight hospitals participated in 166 focus groups across the six visits over the three years. Participants were distributed among the participating hospitals consistent with the size of the hospitals. The participants signed a consent form which the researchers kept separate from the focus group notes and no names were recorded in any of the focus groups; participants were assured they could not be identified.

The structured focus group questions included:

Describe the components of your organisation’s quality system.

What drives service quality improvements in your organisation?

What difference does the organisational quality system make to the quality of patient services?

What is your role in the provision of high quality care? How do you know this?

How does the quality system assist you in the provision of high quality care?

What is your organisation’s definition of high quality care?

What level of quality care do patients receive in your hospital today? How do you know this?

Has the quality of care improved over the past 6 months? How do you know?

What would be helpful to you in further improving the care your patients receive?

The focus groups were not video, or tape recorded to ensure full confidentiality of the participants. The researchers both took detailed notes. The themes arising from the focus groups data were clear and consistent. At baseline data saturation was achieved in all hospitals after only a few focus groups.

To minimise potential bias, the authors strictly followed the COREQ checklist for qualitative studies.²⁷ Using content analysis,^28,29 the authors independently coded the focus group data and then reviewed and agreed on the codes. Only themes agreed by both researchers were included in the final qualitative database. Inter-rater reliability (IRR) was calculated using the approach outlined by Miles and Huberman,³⁰ with 80 to 90% considered acceptable IRR. The researchers agreed on 20 codes [reference removed for peer review], with Researcher 1 reporting 23 total codes for 87% IRR and Researcher 2 reporting 22 total codes for 91% IRR. The themes were consistently strong among all focus groups in all research sites. These analyses were provided to the hospital board members, managers and clinical staff at the next visit (i.e. every six months) who verified the accuracy of the findings.

The Board Quality Committee at each of the eight sites completed a self-assessment of their improvement capability using the Institute for Healthcare Improvement (IHI) Improvement Capability Self-Assessment Tool.³¹ This tool assesses capability on a scale of ‘beginning’ to ‘exemplary’ on leadership for improvement, results, resources, workforce and human resources, data infrastructure and management, and improvement knowledge and competence. The IHI self-reported scores were summarised and compared annually.

Quantitative methods

The Quality System Maturity Scale (QSMS)²⁶ rated the maturity of quality systems from 1. Informal Improvement to 5. Strategic Creation. Two international validated tools were employed to assess the effectiveness of the quality systems: Quality Management Compliance Index (QMCI) and Clinical Quality Implementation Index (CQII).³² The QMCI comprises four scales found in the literature and confirmed by an expert panel to influence the quality and safety of care: quality planning; quality control and monitoring of patient/professional opinions; quality control and monitoring of quality systems; and improving quality by staff development.³² The CQII obtains evidence of the implementation of clinical quality systems relating to seven common clinical risk areas: hand hygiene, medication errors, falls, pressure injuries, pre-operative testing, use of surgical safety checklist and identification of deterioration. It describes five infrastructure levels for each clinical risk area: a responsible group exists; a hospital protocol exists; compliance monitoring; sustainability of the system; and improvement focus.

As required by the validated tools the researchers completed an annual document review of the organisation’s strategic plan; quality framework, quality plan and regular reports; board quality committee minutes and operational quality committee minutes. At every visit the sites provided their measures for eight quality indicators, comprising: hand hygiene rates, medication incidents, patient deterioration, patient falls, pre-operative elective surgery assessments, pressure incidents, staphylococcal bacteraemia (SAB) infections, and surgical checklist. While these measures are recommended by Wagner et al.,³² they are also reported to the government for funding compliance. Using SPSS³³ repeated measures multivariate analysis of variation was used to analyse changes in the experimental and control hospital quantitative data.

Concurrent mixed method data analysis as outlined by Fitzgerald et al.³⁴ was completed after every research visit. The study received approval for the three years from the Human Research Ethics Committee of La Trobe University and the participating hospitals between January and April 2015.

Findings

Implementation of the intervention

The 2015 baseline IHI self-rating and focus group data suggested that none of the eight hospital sites had a fully implemented quality system in place that was self-rated as successful in supporting consistently high quality services. All four SQMS hospitals began implementation in 2015 and first established a definition and strategic goals for high quality care and services with their staff and consumers. Practical point of care actions required to achieve each goal were also identified in this process.

Following the planning, three hospitals commenced implementation. One hospital was unable to progress SQMS because of unforeseen operational challenges. This hospital has been removed from the results. The continuing three experimental hospitals began a defined implementation plan,²⁶ but none fully followed the evidence-based change management approach. Each site reported the difficulties of maintaining a focused approach within the busyness and complexity of the hospital environment. Hospitals reported that instead of systematically following the implementation steps, they used a range of initiatives they thought would work. These tended to be based on the ideas of the quality director and rarely informed by evidence but reported as ‘common sense’ and ‘based on experience’. Some of these steps progressed and some impeded implementation.

Changes in senior staff and quality managers at some of the hospitals added to this challenge, with a negative link identified between leadership turnover and quality management system progress [reference removed for peer review]. The board members and senior managers reported that after the initial enthusiasm SQMS implementation lost traction in the second year, with internal and external distractions, including building works, budget issues, organisation restructures and external policy changes. In the final year of the research, the three experimental hospitals increased their focus on implementation in response to recognition that SQMS was not progressing as desired.

CQII, QMCI and QSMS

Table 1 outlines the change in the CQII, QMCI and QSMS indices from 2015 to 2017. The QMCI scale for quality planning contains only one item and therefore the validity cannot be established. The Cronbach’s alphas for the other QMCI domains ranged between 0.81 and 0.92 for monitoring of patient/professional opinion (6 items), 0.66 and 0.74 for monitoring of quality system (4 items) and 0.80 to 0.88 for improving quality through staff development (4 items). In monitoring of quality systems removal of one item, ‘Q11 Guidelines application are measured and evaluated’, increased the alpha from 0.66 to 0.76. The Cronbach’s alphas for the CQII clinical areas were all acceptable, ranging from 0.74 to 0.97, except for the scale for preventing hospital infection, with alphas ranging from 0.63 to 0.67, for which there was no solution. The QSMS Cronbach alpha was satisfactory at 0.78.

Table 1.

Unit change (% change in brackets) in QMCI CQII and QSMS indices 2015 to 2017 by hospital.

Hospital	2	3 (exp)	4	5	6	7 (exp)	8 (exp)
Change in CQII	−1.6 (−14.0)	0.8 (8.5)	0 (0)	0 (0)	0.4 (3.1)	0.2 (1.6)	0 (0)
Change in QMCI	3.2 (22.0)	3.16 (51.2)	2.69 (34.0)	4.5 (45.0)	0.7 (5.1)	0 (0)	1.1 (8.27)
Change in QSMS	−1 (−25)	0.2 (4.3)	0 (0)	−0.6 (−12.5)	0.6 (14.3)	0.7 (15.5)	0.7 (15.5)

Note: (exp) refers to experimental hospital.

The CQII ranges from 0 to 14 and the study hospitals had a mean of 12.1 in both 2015 and 2017. There was a decrease in one control hospital in the middle of a large building program and positive increases in two experimental hospitals, but otherwise there was little change over the three-year period. In most cases, except for routine testing of elective surgery patients, the participating hospitals, both experimental and control, had the clinical governance components recorded by the CQII in place, such as a responsible group, protocols, extensive monitoring, and a sustainable system.

The QMCI ranges from 0 to 16 and the mean was 11.0 in 2015 and 12.1 in 2017. The QMCI stayed the same for one experimental hospital and increased over time for the other experimental and control hospitals. The greatest area of change was in quality planning. The QSMS ranges from 0 to 5, and while the distribution changed, the mean was 4.2 in both 2015 and 2017. The QSMS increased for the experimental hospitals, and for one control hospital (which identified strategic quality care goals but was not actively pursuing consistent point of care achievement), and either decreased or stayed the same for the other control hospitals.

Quality indicators

The experimental and control hospitals provided the data for the eight quality indicators six times over the three years of the study. Although these are standard quality indicators that the hospitals obtain from clinical and administrative databases and are required to report for accreditation and to the government department of health, only five of the eight variables that were measured consistently by the hospitals, hand hygiene rates (HH), medication incidents (MI), patient falls (Falls), pressure incidents (PI), and SAB infections (SAB) were used for further analysis with repeated measure multivariate regression. Tables 2 and 3 illustrate the variation among these variables in the experimental and control hospital groups over the three years. Hand hygiene compliance and patient falls rates improved for the experimental hospitals, medication and pressure incidents rates worsened for the control hospitals. The other indicators were not appropriate for analysis. The use of a surgical checklist indicator was tracked by seven of the hospitals and was stable, ranging from 92% to 100% compliant. Only three of the sample hospitals collected the pre-operative elective surgery assessments, and various metrics were used to track deteriorating patients, such as number of MET calls, number of late MET calls and rate of core observations recorded, making it impossible to make comparisons among the hospitals.

Table 2.

Quality outcome indictors average for control hospital group (n = 4).

Time	1	2	3	4	5	6
Hand hygiene (% non-compliant) (HH)	17.97	19.70	16.60	14.98	17.20	14.53
Patient falls rate/1000 bed days (Falls)	3.48	3.00	3.33	2.76	2.44	4.14
SAB rate/10,000 bed days (SAB)	1.28	0.40	0.51	0.62	0.70	0.60
Medication incident rate/1000 bed days (MI)	3.25	4.91	5.18	6.31	7.98	6.17
Pressure incidents/1000 bed days (PI)	0.41	0.58	0.51	0.73	0.62	0.68

Table 3.

Quality outcome indictors average for SQMS hospital group (n = 3).

Time	1	2	3	4	5	6
Hand hygiene (% non-compliant) (HH)	17.57	12.80	12.00	9.33	13.73	11.67
Patient falls rate/1000 bed days (Falls)	2.42	2.61	1.74	1.27	1.46	1.11
SAB rate/10,000 bed days (SAB)	0.00	0.67	0.40	0.53	0.23	0.00
Medication incident rate/1000 bed days (MI)	8.89	3.92	3.67	4.58	3.84	3.04
Pressure incidents/1000 bed days (PI)	0.03	0.94	0.58	0.41	1.15	0.25

As seen in Table 4 the experimental group of hospitals was associated with lower rates of hand hygiene non-compliance than the control hospitals (p = .048). There were no significant differences in any other variables.

Table 4.

Repeated measures multivariate between group analysis.

Source	Measure	Sum of squares	df	Mean square	F	Sig
Intercept	HH	10524.344	1	10524.344	175.304	.000
	SAB	22.929	1	22.929	14.404	.013
	PI	13.715	1	13.715	4.436	.089
	MI	164.274	1	164.274	8.513	.033
	Falls	175.655	1	175.655	5.437	.067
Exp control	HH	406.622	1	406.622	6.773	.048
	SAB	.477	1	.477	.299	.608
	PI	.014	1	.014	.005	.949
	MI	3.483	1	3.483	.181	.689
	Falls	3.693	1	3.693	.114	.749
Error	HH	300.175	5	60.035
	SAB	7.959	5	1.592
	PI	15.457	5	3.091
	MI	96.488	5	19.298
	Falls	161.529	5	32.306

Focus groups

Control hospital focus groups

The findings from the focus groups were consistent across both experimental and control hospitals at the first visit and have been reported elsewhere [reference removed for peer review]. The first theme was the gap between Board and management aspirations for quality care and staff understanding of and engagement in quality management. Board and executive were optimistic about the impact of their quality management system on care. The executives believed that their staff were competent, that staff knew what was expected of them regarding care quality and that quality improvement systems and processes were in place and effective. The clinicians and middle managers told a different story of their relationship with the quality system; reporting lack of communication about quality and quality improvement expectations and implementation, and inadequate support for them to provide consistently high quality care.

The second theme was that staff saw their quality systems as reactive, compliance-focused and complex. Staff identified their organisation’s quality system as a series of tasks: incident reporting, reactive risk management, compliance with standards and evidence requirements, meetings and mandatory training. In the absence of a meaningful purpose and obvious point of care benefits for staff and consumers, these tasks were seen by staff as an end in themselves, often labelled as ‘doing quality.’ They felt that the focus was less on improvement, and more on monitoring the status quo and reacting when things went wrong; incremental changes related to compliance which were not always sustained.

Although each hospital had a quality plan comprising numerous monitoring and improvement initiatives, much of the activity was focused on risk, compliance and consumer feedback, as key requirements of accreditation standards, and on access, driven by funding policy. This is not to say that these hospitals were not actively pursuing quality care; there were many projects that demonstrated improvement, overseen by enthusiastic leaders, managers and staff, but these lacked an overarching system to capture, synthesise and spread achievements, and maintain momentum. Apart from noting specific positive improvement initiatives as they were introduced, such as leadership training, falls reduction and anti-bullying programs, these perceptions of the focus group participants in the control hospitals regarding their organisational quality systems did not change over the three years.

SQMS hospital focus groups

Focus groups themes changed among the SQMS hospitals over the study timeframe. With regards to the first theme, of the gap between the aspirations of management and the understanding and engagement of staff, in comparison to the first focus groups, the last visit focus groups, three years later, demonstrated some improvement. There was a more united executive voice on point of care quality priorities, increased awareness of the gaps in their quality system to achieve these priorities and more enthusiasm to continue to promulgate the SQMS across the organisation. However, other themes emerged among the experimental hospitals including, lack of implementation skills and the everyday busyness and distractions involved in running a complex service, that were acknowledged by hospital participants as barriers to progress, as outlined below.

SQMS 3

The executives reported early in the third year of the project that, “We dropped the ball on [the SQMS] implementation as accreditation intervened” (Board and senior management, Regional/rural (R/R)3 FG#8) and “The message of the [SQMS] got lost in the standards” (Board and senior management, R/R3 FG#11). They also admitted that they purposely skipped implementation steps because they “were too basic”. Despite successful accreditation results within the study period, they realised that they had not progressed staff understanding or practice in terms of pursuing the quality goals at point of care. This realisation resulted in re-energised implementation to embed the agreed quality definition and goals throughout the hospital in the final year of the program.

The final focus groups in this hospital exhibited a mix of sentiments among clinical leaders, with some saying, “Care has not changed – we have always known we are very good, but now we can express it better – report it better”; and others: “We have matured and have more knowledge about patient complaints and what they mean” (Clinical leaders, R/R3 FG#12). At the end of 2017 focus group participants mentioned ‘good catches’ and greater awareness of the expectations of executive that good care should be more ‘personal’ suggesting greater understanding compared to 2015 and 2016.

SQMS 7

In the final year, the executives in this hospital reported that, “The building project took our focus away from quality. There was a negative impact on quality of care” (Board and senior managers, R/R7 FG#15). In addition, they suggested that implementation went backwards over time because they did not have a change management plan: “the Quality Manager needed to find out for herself that just telling people was not enough of a change strategy” (Board and senior managers, R/R7 FG#15). They felt they were back on track with a change management plan and process. They noted that the strategic approach “prompted them to think about quality care in a different way – in a more appropriate way” (Board and senior managers, R/R7 FG#15). The clinical leaders in the final focus group suggested that staff had become more involved in improvement and were making posters on what the SQMS meant to them, but that it was too early to say whether the SQMS influenced patient care.

SQMS 8

In this hospital, focus group participants also recognised that the SQMS implementation process had been inconsistent over the study period, with the distractions inherent in running a large complex organisation slowing progress. The implementation steps were not followed once the strategic quality system passed the initial implementation phase. However, in 2017 the managers and staff displayed a shared view of high quality care, encompassing a broader understanding than the other two experimental hospitals and the control hospitals. Even the medical staff, who are often sceptical about quality systems, noted that the SQMS made clinical sense, and reported that it had assisted them in decision making and prioritisation of care decisions, “You can get cynical about management stuff, but don’t get cynical about the new approach [the SQMS], you can introduce things from this system that make sense.” (Clinical leaders Metropolitan (M) 8 FG#18) and “Patient was demanding a female anaesthetist – it helped to pull out the [SQMS] framework to say to my staff that we should accommodate this.” (Clinical leaders M8 FG#18).

Discussion

This study extends previous studies by measuring the impact of a strategic quality management system, designed to emphasise the ‘planning’ component of Juran’s Quality Trilogy.¹⁰ Over the three-years none of the control hospitals actively pursued a strategic quality management approach. At the start one hospital had strategic goals for high quality care, and used them to guide improvement activities, but they did not have a plan to systematically work towards quality goal achievement for every patient. The control hospital quality systems showed little evolution over the three years, with a continuing focus on clinical governance and operational improvement plans largely addressing clinical risk and achieving accreditation and funding requirements.

These quality activities were deemed as successful by Board members and management. Both the CQII and QMCI indices were substantially higher for the control (and experimental) hospitals than 74 European hospitals measured with these scales,³² suggesting that these hospitals had quality systems in place. However, our qualitative findings illustrated that clinicians and their managers in the control hospitals reported difficulty understanding how the quality and risk initiatives supported day to day care. In the absence of point of care-focused goals for care, clinicians and local managers identified their organisation’s quality system as the tasks associated with compliance, predominantly incident reporting, risk management, meetings and mandatory training. Staff perceived that their hospital’s quality system focused on control and improvement primarily to meet, what they perceived to be, bureaucratic compliance requirements. As others have found, this was a barrier to their understanding of and engagement with improving point of care quality.³⁵ Without a clear point of care purpose for quality activities, completing these tasks was seen by staff as an end itself, labelled as ‘doing quality’, rather than a useful support to better service delivery.

As long as compliance was achieved, the leaders in the control hospitals were not motivated to develop a more strategic approach³⁵ and made few, if any, changes in response to the researchers’ feedback at each visit. Board members, executives and quality managers in the control hospitals believed that compliance-focused quality management was sufficient. This belief persisted even though their clinicians described the quality system as unhelpful, and there was no recorded improvement in the quality indicators tracked over the course of the study, with negative trends observed in medication incidents and pressure incident rates. Accreditation status was offered as proof of successful quality management. This is an important finding, suggesting that lack of a shared definition of high service quality, encapsulated within clear goals, allows the governing body, executives and managers to judge the success of their quality system on the degree to which it meets compliance requirements. This can foster a false sense of security that the quality system supports staff to deliver high quality care to a greater extent than it does,³⁵ perpetuating an organisational culture that does not support quality improvement.¹²

While all four hospitals commenced the SQMS implementation, as outlined above, one hospital was not able to make any progress and was removed from the analysis. In addition, none of the remaining three experimental hospitals fully followed the suggested process over the three years. It appeared that the executives overestimated their ability to influence local staff action, despite the evidence that clinicians must be actively engaged in quality systems development for it to be meaningful.³⁶ Motivating staff in a complex healthcare organisation to achieve a common goal for high quality care is challenging,³⁷ and the deviation from the recommended implementation steps resulted in limited attention to the cultural and social processes required to support consistently high quality care [reference removed for peer review]. Early implementation was replaced by overemphasis on the bureaucracy of quality such as policies, procedures and rules, as this was their existing approach. Achieving consistently high quality care requires recognition of the judgement and experience of those providing the services; “not blindly following rules,”³⁸ (p. 420), but although this was built into the recommended implementation steps and discussed at the research visits, making rules for staff was the preferred approach to implementation, at least initially.

Despite the difficulties with implementation, there was evidence of greater clinician engagement in pursuing the quality goals among the SQMS hospitals by the third year of the study. In the final focus groups, many of the clinical staff identified the SQMS as the quality system in their organisation and could discuss the degree to which the definition and goals for high quality care helped them provide better care. Not all agreed that it had resulted in better care, but some were using it to develop a greater patient focus with their staff, or to relate technical developments, such as a new electronic medical record, to a desirable point of care focus and results.

Clinical managers in two SQMS hospitals noted that the SQMS made clinical sense and helped them to remind staff about what was important at the bedside, using the goal-related measures developed by their hospital to discuss progress towards high quality care in their service. The experimental hospitals also demonstrated significantly higher levels of hand hygiene compliance than the control hospitals, a further sign of clinician engagement.³⁹ These findings suggest that a strategic quality management system, comprising the planning, improvement and control components advocated by Juran can promote a whole of organisation approach to quality. The specific steps comprised strategic quality planning, goal setting, implementation via a defined pathway designed to engage staff in goal achievement, and quality improvement and control related to achieving the goals. These hospitals were also able to integrate quality compliance and funding requirements into their actions to achieve the quality goals.

Given the lack of full implementation of the SQMS, we were not able to fully answer the research question. However, our results suggest that the implementation of a strategic quality management system (SQMS), drawing on the Juran Quality Trilogy with a focus on the ‘planning’ component, had the potential to be associated with better quality care than that which currently exists within compliance-focused quality management systems.

The SQMS hospital board members and executives reported that they considered the researchers’ feedback at every visit and used it to improve implementation, appearing more attuned to feedback and using data for problem sensing⁵ than the control hospitals. This may have been because the SQMS hospitals had defined goals to achieve and a commitment to pursuing them while the control hospitals were meeting their compliance requirements. At the conclusion of the study, the executives and staff of the SQMS hospitals were discussing external compliance requirements as part of their quality strategy, not as the point of their quality strategy. As recommended by others they had evolved the way they connected strategic, compliance and operational activities to achieve the quality goals.⁴⁰ In this attitude and approach, the beginnings of socialising a Quality Trilogy approach of planning, improvement and control as ‘business as usual’ were evident.

Practice implications

Our findings suggest that the strategic planning component of the Quality Trilogy was not routinely implemented in our sample of eight Australian hospitals. We believe that this is a significant missing link in the pursuit of consistently high quality care. Implementing a strategic quality strategy that sets organisational goals for service quality is challenging, but achievable. We pose four lessons from our research that, if addressed, would enhance hospital quality systems:

First: the belief that a quality system is successful if accreditation is achieved, promotes dangerous complacency about the quality of care experienced by consumers and the level of staff engagement in improving care. This complacency may be constraining the evolution of quality systems. In contrast to the control hospitals, by the end of the study the SQMS hospital executives and staff shared a common aspiration for and definition of high quality care and a realistic understanding about their gaps in achieving it. Developing strategic goals for quality as the purpose of the quality system appears, over time, to create a clearer view among decision-makers of what it takes to create consistently high quality care and more focused action in pursuit of it. It also encourages integration of compliance and funding requirements into the quality strategy providing greater context for staff.

Second: board and executive members in each hospital initially shared the belief that their staff inherently understood what was expected and required to provide high quality care, and that changes to the way that quality was pursued were either not required or could be achieved by emphasising new or existing rules. This was challenged by staff opinions of the lack of clarity and support, with many staff associating ‘quality’ with tasks and bureaucracy, rather than the care they provided. Considering the evidence on the critical importance of an engaged and supported workforce in pursuing high quality care,^5,12,32 this lack of congruence should be addressed in quality system planning and implementation. Managers and staff working together to create a shared vision and process for achieving high quality care, as advocated by Juran, can increase both congruence and engagement, build a more realistic picture of how quality care is pursued, and help to integrate the cultural and social processes required to sustain high quality care.¹³ This also requires hospital leaders to commit to systematic but flexible implementation processes that integrate evidence about motivating and supporting staff to achieve and sustain high performance in complex systems.

Third: the way in which quality was measured was a barrier to staff understanding and involvement in improvement. Staff complained that much of the quality data required for bureaucratic purposes were unrelated to their job responsibilities. As also reported by Jiang et al.,⁴¹ staff felt that quality data were unhelpful for monitoring or improving the quality of their work or motivating them to act. Quality measures must be designed and reported to inform clinicians and managers about quality care so that they are motivated to act to reach agreed levels of quality, and to manage risks.

Fourth: maintaining a consistent focus on quality was an ongoing problem in each hospital. All leaders lost focus at various times, due to distractions such as major projects, building works, funding issues, quality problems and external reporting or compliance requirements. Executive staff turnover, particularly when it was the CEO, slowed progress or altered direction. Boards and executives may be unaware of the impact of these seemingly unrelated issues. Triggers to raise awareness of the quality implications of distractions common to hospitals could be built into quality system design and implementation.

Theoretical implications

This study contributes to quality management theory and strategic planning and management theory. The study confirms the importance of quality management that includes all aspects of the Juran Quality Trilogy, comprising quality planning, quality improvement and quality control. External pressures that have heightened the focus on quality control were seen to reduce the emphasis on quality planning in our sample hospitals, with limited positive impact improving quality of care. The focus on quality planning through the SQMS in the experimental hospitals was associated with better staff engagement in quality management in comparison with the control hospitals. This favourable staff engagement was seen in the focus group data and the quantitative results for hand hygiene practices. These findings are consistent with the barriers to quality management identified by Mosadeghrad, poor planning without a strategic focus on quality and top down direction hat was associated with lack of staff engagement.⁴²

In relation to strategic planning and management theory, consistent with the findings of other studies, implementation is an essential aspect of strategic planning and management¹⁵ that often fails. The experimental hospitals in our sample had the same difficulties with strategy implementation that have been found in other studies.¹⁵ This included implementation taking longer than expected, resulting in unhelpful shortcuts, difficulties in engaging staff and organisational ‘crises’ reducing the attention on implementation.

Limitations

Hospitals are complex and cannot be easily randomised to intervention and control groups to study causality.⁴³ Despite the substantial data analysed in this study, three years was insufficient time to fully implement a SQMS and observe related changes in quality indictor results. There is an urgent need for more longitudinal studies that provide solid evidence on the strategic and leadership actions that are associated with higher quality care.

Conclusions

The focus on quality and safety has increased exponentially over the past decade, but pre-occupation with compliance has not achieved the corresponding gains in sustained point of care quality. Our findings suggest that a strategic quality management system, comprising a shared definition and goals for high quality care, a specific implementation pathway incorporating both system and socialisation guidance, and quality improvement and control systems related to achieving quality goals, has benefits for consumers and staff. Implementation is clearly challenging, and this research has identified some of the hurdles impeding progress. The experimental hospitals demonstrated that progress can be made, despite these challenges, leading to higher levels of manager and staff understanding of and engagement in the pursuit of service quality. Even the most elegantly constructed quality systems, if focused on quality control and improvement that clinicians feel is unrelated to their daily work, are unlikely to influence the quality care that health care staff and consumers want – and need.

Supplemental Material

sj-pdf-1-hsm-10.1177_0951484820943601 - Supplemental material for Making high quality care an organisational strategy: Results of a longitudinal mixed methods study in Australian hospitals

Supplemental material, sj-pdf-1-hsm-10.1177_0951484820943601 for Making high quality care an organisational strategy: Results of a longitudinal mixed methods study in Australian hospitals by Cathy Balding Sandra Leggat in Health Services Management Research

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sandra Leggat

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