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Abstract
Background Patient safety has been high on the agenda for more than a decade. Despite many national initiatives aimed at improving patient safety, the challenge remains to find coherent and sustainable organisation-wide safety-improvement programmes. In the UK, the Safer Patients' Initiative (SPI) was established to address this challenge. Important in the success of such an endeavour is understanding ‘readiness’ at the organisational level, identifying the preconditions for success in this type of programme. This article reports on a case study of the four NHS organisations participating in the first phase of SPI, examining the perceptions of organisational readiness and the relationship of these factors with impact by those actively involved in the initiative.
Materials and methods A mixed-methods design was used, involving a survey and semistructured interviews with senior executive leads, the principal SPI programme coordinator and the four operational leads in each of the SPI clinical work areas in all four organisations taking part in the first phase of SPI.
Conclusions This preliminary work would suggest that prior to the start of organisation-wide quality- and safety-improvement programmes, organisations would benefit from an assessment of readiness with time spent in the preparation of the organisational infrastructure, processes and culture. Furthermore, a better understanding of the preconditions that mark an organisation as ready for improvement work would allow policymakers to set realistic expectations about the outcomes of safety campaigns.
- Organisation
- collaborative programme
- organisational readiness
- quality improvement
- safety programme
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Introduction
Patient safety has been high on the agenda for more than a decade, and the risks to patients are well known.1–5 Despite many national initiatives aimed at improving patient safety, the challenge remains to find coherent and sustainable organisation-wide safety-improvement programmes. In 2004, the Health Foundation began the ‘Safer Patients’ Initiative' (SPI1), funding four NHS organisations to work with the Institute for Healthcare Improvement using their ‘breakthrough’ collaborative model, focusing on the reliability of care.6 7 This programme was the first in the UK aimed at achieving organisation-wide improvements in patient safety (box 1). Participating organisations signed up to a long-term developmental journey intended to bring about significant organisational change. In 2006, a further 20 organisations began a similar journey (SPI2).
The assumption in the NHS is that organisations should be equally capable of responding to national initiatives and guidance. It seems more likely that they will vary in their capacity to respond; indeed, recent research found that clinical systems improvement cultures and techniques were largely not embedded in NHS organisations.8 Studies investigating organisational change in healthcare have reported ‘organisational readiness’ as a vital prerequisite for success.9 10 The key factors from these studies11–20 include:
tension for change;
leadership style and commitment to safety and quality;
consistency with existing goals;
sound management processes and meeting government targets;
organisational stability;
past history of successful change;
culture and environment for improvement work.
Uncertainty due to organisational change has been highlighted as affecting the success of programmes21 with mergers found to introduce periods of ‘intensive introspection’ that set organisations back.17 Clearly, understanding ‘readiness’ at the organisational level together with assessment of an organisation against these is vital for ensuring the success of programmes such as SPI.
This paper describes a case study of the four organisations in SPI1, investigating the extent to which the readiness themes in the literature could be applied and considering what additional factors might emerge. Through survey measures and interviews, we examined the perceptions of organisational readiness of those actively involved in SPI1 as it applied to their organisation's success in implementing the initiative. Success of such programmes is difficult to measure objectively at the organisational level. Our working definition for this study was therefore whether the programme continued to be spread in each organisation; whether data were still being collected and reported; whether it still had the attention and involvement of the Chief Executive; and to what extent it had been incorporated into general management rather than being run as a separate project.22
Materials and methods
Research design
The study involved the four SPI1 sites, referred to as Trusts A–D, to preserve confidentiality. A mixed-methods design was used, involving both qualitative and quantitative data collection through semistructured interviews and surveys.
The study took place in late 2007 at the end of Institute for Healthcare Improvement support but during a period of continued development. A systematic sampling strategy was employed to include the SPI improvement team in each organisation comprising: the senior executive leads, the principal SPI programme coordinator and the operational leads in each of the clinical work areas. Individuals were recruited by local site coordinators. Forty-one survey responses were obtained with a 90% response rate (see table 1). Thirty-four of these participated in the interviews (n=34).
Respondents' characteristics
Survey measures
The survey included a range of items relating to organisational readiness. Respondent demographic data were recorded relating to: organisation, SPI work stream (see box 1), and level of role in terms of proximity to frontline services (either board level or clinical frontline).
Box 1 Details of the safer patients initiative programme
Collaborators
The Health Foundation; Institute for Healthcare Improvement; 24 UK National Health Service Trusts across England, Wales, Scotland and Northern Ireland.
Main aims
Mortality: 15% reduction
Adverse events: 30% reduction
Ventilator-associated pneumonia: 0 (or 300 days between)
Central-line bloodstream infection: 0 (or 300 days between)
Blood sugars within range (ITU/HDU): 80% or >w/in range
MRSA bloodstream infection: 50% reduction
Crash calls: 30% reduction
Harm from anticoagulation: 50% reduction in ADEs
Surgical site infections: 50% reduction
Programme structure
Phase 1: Pilot phase involving four organisations 2004–2006
Phase 2: Main phase involving 20 organisations 2006–2008
Safer Patients' Initiative work areas and associated change package elements
Medicine management
Medicine reconciliation
Anticoagulant management
Leadership
Leadership walkarounds
Critical care
Ventilator bundle
Central line bundle
Perioperative care
Safety briefings
Hair removal, normothermia and antibiotic prophylaxis
General ward care
SBAR
Hand hygiene
Early warning scoring system
Generic tools/techniques
PDSA cycles and small tests of change
Incremental spread methodology
Process measurement and SPC analysis
Overview of programme methodology
Learning sessions
Extranet
Monthly evaluation
Expert support (list-serv, conference calls) http://www.ihi.org/IHI/Programs/StrategicInitiatives/SaferPatientsInitiative.htm
Respondents were asked: ‘How ready was your organisation at the start of SPI for successful implementation of the programme?’ Responses were made against three subscales: (1) culture and attitudes towards quality and safety; (2) systems and infrastructure; and (3) availability of resources. Ratings for each were made on a six-point scale, ranging from 1 (‘low readiness’) to 6 (‘high readiness’). In addition, respondents were asked to rate the degree of organisational change prior to SPI, using a scale ranging from 1 (‘stable’) to 6 (‘turbulent’).
The survey included a section asking: ‘To what extent were the following factors a weakness or strength in implementing SPI?’ Fifteen items were presented with a rating scale for each ranging from 3 ‘Significant strength’ to −3 ‘Significant weakness,’ with a zero centre point ‘Neither.’ Items included: financial resources, goal-compatibility, systems/processes, selection of interventions, senior management support, doctor support and process measurement (table 2).
Perceptions of specific readiness factors for Safer Patients' Initiative (SPI) by organisation ranked by mean score
Interviews
A standardised research topic guide was used during the interviews by two interviewers, which were recorded with participants' permission. In the introduction, the interviewees were given an overview of the research questions of interest. The questioning was open-ended, allowing exploration of the issues, informed by the researcher's knowledge of research findings in this area. Further questioning and prompts were designed to elicit any additional factors perceived by the respondents to be important. For example: how had the application to participate come about, and what had motivated this? What safety and quality initiatives were already under way? How novel SPI was in the context of the organisation at the start of the programme? What were the most important things that had to be in place at the start for SPI to work? Interviewees were also asked to comment and expand upon their rationale for their survey responses relating to readiness and organisational stability prior to SPI.
Data analysis
All interviews were transcribed and analysed using the constant comparative technique for inductive open coding and axial coding, using NVivo software.23 Two researchers were primarily responsible for the qualitative analysis with regular input from three other researchers, with diverse backgrounds, to ensure multiple perspectives and consistency in coding. Broad inductive open coding was initially performed. Elements from the transcripts were included if: (1) they related to conditions originating before or at the outset of SPI; and (2) they positively influenced the SPI programme. Raw codes were then selected and combined into higher-level categories through iterative comparison and refinement. In this sense, analysis proceeded both deductively, to impose structure on the emerging readiness model, and inductively, to allow new insights from the data to emerge and be defined in the analysis.
The survey data were analysed, and both respondent groups and specific variables were compared for differences. The data did not meet parametric assumptions, so non-parametric tests were used. Kruskal–Wallis tests were performed to investigate group differences (α 0.05) with Mann–Whitney post hoc comparisons adjusted for multiple comparisons (using the Bonferroni principle). Comparisons between individual variables which used the same response scale were made using Friedman ANOVA tests (α 0.05). Spearman rank order correlation coefficients were calculated to identify any significant correlations between readiness and other variables.
The interview findings were compared with the survey results in order to confirm whether there was any agreement in our fundamental conclusions from both methodological measures.
Results
Respondents' characteristics are set out in table 1, showing a spread across the principal work areas and a mix between clinical frontline staff and those at senior/executive level.
Perceptions of organisational readiness variables
Table 3 presents the data for the organisational readiness and organisational stability items. For the total sample, organisational readiness in terms of ‘culture and attitudes’ was rated significantly higher than both ‘systems and infrastructure’ (z=−4.806, p=0.00) and ‘resource availability’ (z=−4.730, p=0.00).
Perceptions of organisational readiness and organisational stability by organisation
All organisations rated their readiness in terms of culture and attitudes highest and resource availability lowest. Their aggregated scores of general organisational readiness and their ratings of organisational stability were around the mid range. There were no significant differences between the four sites.
Qualitative analysis of interview transcripts yielded four themes relating to organisational preconditions for safety improvement set out in table 4.
Illustrative interviewee quotations on organisational preconditions
All organisations reported that their improvement track record was important in enabling them to embark on the programme, while at the same time they all experienced difficulties with the adequacy of their existing systems for data collection and measurement. The importance of being in financial balance and meeting other targets was of particular importance to the senior executives, although not easy to achieve for some involved.
Perceptions of specific readiness factors for SPI
Table 2 presents the specific readiness factors for SPI and respondents' ratings. Overall, respondents rated most factors as strengths. While nursing and clinical management support were rated as good at the start, ‘doctors’ support for the programme' was rated as a weakness. The results also support findings from other research8 that, despite a range of modernisation and collaborative improvement programmes in the NHS in the past, there is still variation in understanding of the concepts and tools for quality improvement.
Illustrative quotations from the interviewees identifying important factors at the start of the programme are included in table 5.
Interviewee quotations on safer patients initiative (SPI) programme readiness factors
These illustrative quotes show that taking time to reflect on the influence of the conditions at the start of a change programme can provide valuable learning for organisations. Of importance here was the selection of the right people to be involved, getting the right programme management structure, engaging clinicians and communicating to the wider organisation.
Correlations between readiness and impact factors:
Overall organisational readiness ratings were significantly positively correlated with: ‘effect of SPI on quality and safety performance in the trust’ (r=0.370, p<0.05), ‘sustainability of SPI benefits’ (r=0.439, p<0.01) and finally ‘success in spreading throughout the organisation’ (r=0.349, p<0.05). There was a significant negative correlation here with the ‘degree to which SPI was driven by a top down or bottom up approach’ (r=−0.309, p<0.05).
The ‘aggregated score of specific readiness factors for SPI’ was significantly positively correlated with the ‘effect of SPI on quality and safety performance within clinical areas’ (r=0.637, p<0.01).
Discussion
The emerging readiness model from our analysis provides specific, grounded examples of how several important and established organisational readiness factors impact upon the process of organisation-wide safety improvement initiatives such as SPI.
The teams leading the implementation of SPI perceived their organisations to be well prepared at the start in possessing the ‘right’ culture, attitudes and values, as well as having suitably motivated people to lead the changes. This appears to have ensured a receptive environment at the outset.
The finding that a ‘bottom up’ front-line-led approach was associated with a high rating of general organisational readiness suggests that the leadership style in an organisation is an important readiness factor. Other research in this area has found that organisational change is more likely to succeed if staff feel empowered, where formal leaders are not afraid to let others lead the change work.19 20 24 This is an area warranting further research to understand the requirements of managers in safety improvement in particular at middle management level. SPI as an intervention brought Chief Executives into regular contact with front-line clinical staff where the change effort was focused but did not involve middle managers.
Interviewees described a history of involvement in quality-improvement programmes as providing advantage. However, they also referred to involvement with other initiatives as a possible strain on existing staff. The challenge at the outset clearly lies in the effective integration of parallel improvement activities. In a study examining organisational change, Beer et al25 found task alignment to be a key factor for a programme's success, noting the challenge this poses for large organisations.
The qualitative evidence suggests that financial balance and meeting performance targets may be a precondition to permit organisations to focus on quality and safety, since pressures to meet targets compete for senior leadership time. The impact of the financial position of an organisation on its ability to improve patient safety is clearly relevant in the current climate and warrants further attention.
Interviewees viewed medical engagement as essential for the programme's success, in accordance with other research in this area26; however, the survey results found doctors' support for SPI to be problematic. The process of developing ‘active’ medical engagement from ‘passive acceptance’ clearly needs to be understood from a social research perspective.
Interviewees in this study described a range of mechanisms by which they considered specific organisational preconditions to have influenced the course and success of the programme22 supporting findings of other research in this area. A specific example concerns the requirement to collect and report a range of process measures to guide the improvement efforts. Interviewees revealed that the organisations varied in their initial capability for this, highlighting the need to commit time and resources to establishing the necessary infrastructure at the outset.
Limitations
As a preliminary study, any effects and findings reported here warrant replication and further investigation. The research included all the sites participating in SPI1, focusing on those actively involved in leading the work. There is clearly a need within any follow-up study to sample more front-line views to counter the bias of those in leadership positions and to understand the perspectives of those not immersed in the initiative. A finding from a recent study by the current authors examining the impact of SPI22 found that the answers given by senior leaders and frontline clinicians differed on questions relating to management engagement, with senior leaders having a much more positive view of their role than others. Perceptions of organisational readiness are therefore likely to vary between staff groups representing different perspectives on the issue.
A further limitation is the cross-sectional retrospective design that does not allow for causal inferences to be established between organisational readiness variables and impact factors. It is also important to consider that the participating organisations applied to be involved and were chosen according to a site-selection process which may affect how generalisable our findings are beyond the four organisations included in the study. The support that this study offers for readiness factors identified from previous research in health care and other domains would suggest, however, that the findings are broadly applicable.
Conclusion
In this study, we have sought to establish a basis for future research into the issue of organisational readiness for patient-safety-improvement programmes at the organisational level. The findings show that if such programmes are to be successful, all aspects of an organisations infrastructure, processes and culture should be considered in advance.
These issues are timely, given that national patient safety campaigns are under way across the UK, based on SPI. From a practical viewpoint, the implications of understanding organisational readiness for improvement are twofold. First, it would allow organisations to concentrate their efforts on addressing the readiness factors, enabling them to proceed with a greater confidence of succeeding. Second, a better understanding of the preconditions that mark an organisation as ready for improvement work would allow policymakers to set realistic expectations about the outcomes of these campaigns.
References
Footnotes
Funding The Health Foundation (funder); The National Institute for Health Research (funder).
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.