The managerial perceptions from different sectors and levels of the health care system have real implications that should be addressed at policy level and lead to an early review of the role of management and leadership style in the HSE in particular, write Prof. Stiofan de Burca and Dr. Peter Williams.
A major research study among health managers in the HSE, voluntary hospitals, non statutory agencies and the private sector on their perspective of health reforms in Ireland over the last five years has shown paradoxical findings in the HSE responses.
In preliminary findings, the study carried out by the Health Systems Research Centre UL and the HMI revealed that on the one hand there is a matched deterioration in individuals` sense of engagement, with general disimprovement in most aspects of culture and governance, resources and functions. On the other hand, there is improvement in performance management (apart from certain important phases of the planning cycle), quality improvement (internal more than external), and the main service categories other than mental health and intellectual disability and integration within and between services.
There is a matched deterioration in individuals` sense of engagement, with general disimprovement in most aspects of culture and governance, resources and functions
The Voluntary Hospitals, Non-Statutory Agencies and Private Sectors report better individual engagement which corresponds with most aspects of their culture, governance and functions. The Private Sector followed by the Non-Statutory Agencies show more positive indications than the Voluntary Hospitals. These sectors nevertheless all share a clear improvement in performance management (including planning) and substantial improvement in quality and performance activities.
The Private Sector, followed by the non HSE Sectors, shows a more positive overall integrated positive profile and performance. It is of course recognised that they are generally less complex and diverse organisations and do not experience the same direct impact of the reforms as the HSE. All share concerns about resource availability but the HSE and Voluntary Hospitals are probably more sensitive in that regard. The common improvement in performance and quality activities may be attributed to central direction and public demand in the light of critical incidents on such matters. They, and other dimensions, particularly in the HSE, also raise issues of sustainability and effectiveness over time. There are stark contrasts in culture and governance as between the HSE and other Sectors although they mostly share a common perspective regarding the status of national services overall.
The managerial perceptions from different sectors and levels of the health care system have real implications that should be addressed at policy level and lead to an early review of the role of management and leadership style in the HSE in particular. As a starting point, the institution would need to address the fundamental questions of trust and control.
There are stark contrasts in culture and governance as between the HSE and other Sectors
The model and approach link the over-arching elements derived from the analysis of the data. This is presented in the following in respect of the HSE and the voluntary hospitals and others.
Individuals’ Engagement: Of immediate note is the similarity reported between deterioration in individual managers’ sense of engagement with the organisation, and strong corresponding views on disimprovement in the culture and overall governance of the HSE.
Culture: There are major concerns regarding values at most levels of the HSE. In particular, a clear disimprovement in trust in and collaboration/cohesion across the organisation is indicated. Public trust was even lower than internal trust! Although organisational communications with patients has distinctly improved (59 per cent report improvement), there has been little or no improvement in communications with local and national media. In relation to communications with staff, although there are divergent views at all levels, local level notes a net improvement (53 per cent) whereas area and region show disimprovement, with no change at corporate level.
Corporate leadership style is oriented to the autocratic (56 per cent) and authoritative (17 per cent). This lies in contrast with predominantly democratic (34 per cent), transactional (22 per cent), and autocratic (18 per cent) style attributed to the immediate supervisor. Transformational leadership is the least indicated at seven per cent.
Organisational control is polarised at the extreme of being more highly centralised, and prescriptive (as opposed to empowered). This resonates with financial and employment authorisation being substantially limited, eg 51 per cent do not have any budget, while 19 per cent reported a budget of €10 million or more, and this in an organisation with an annual budget circa €16 billion.
Governance: Corporate structure, lines of authority and accountability, and lateral role relationships, all reported major disimprovement at all levels.
In contrast clear and substantial improvement was reported in the quality approach and clinical governance across all levels, although there was no clear improvement in service governance.
Functions: With regard to resource capacity currently available, while there is a clear improvement in Medical Technology, there is no improvement in ICT and Estate, and a major disimprovement in both the overall scale of funding (64 per cent) and personnel (60 per cent).
The operation of Function activities, including management capacity of systems and performance, shows no real improvement. Specifically, there is a very clear disimprovement in the operations of HR (55 per cent).
Performance Management: There is strong concordance on improvement in performance- standards, indicators and measures. However, no change was noted for shared goals and agreed targets. Regarding corporate accountability (for all of these and related objectives), 36.9 per cent reported improvement, while 23 per cent indicated no change, and 40.1 per cent reported disimprovement, 43 per cent of which reported great disimprovement.
Regarding the planning cycle, availability of relevant data, information & data analysis, and monitoring improved substantially, with no change in adoption & implementation, and due process. There was some disimprovement in the involvement of relevant parties and the availability of substantive choice. On balance, however, there is no clear change overall.
Quality/performance improvement: Quality improvement activity overall has distinctly progressed, particularly that driven internally with 64.5 per cent, and external showed clear improvement with 55 per cent… However, performance improvement (individual and organisational learning, and sustainable achievement) showed a clear disimprovement, in particular at area, region and corporate levels.
In specific areas great progress was reported (over 75 per cent) for internal quality activity in respect of Risk Management, Patient Safety, Hygiene Audit, and Health & Safety, followed by Care Pathways, and Clinical Audit, with a slight improvement in service audit, and peer review. Staff input showed no change overall. In externally oriented activity, hospital accreditation and critical events investigation improved greatly, and there was clear improvement in department accreditation, with no clear improvement in professional licensing, external evaluation, and patient/community input.
National Services: Within the sample of care categories considered, some progressed very well (Cancer, Cardiovascular), yet there was little or no change reported overall for others (Mental Health and Intellectual Disabilities).
It is generally agreed strongly across all sectors and levels that primary care improved substantially (70 per cent). Tertiary care shows a clear if small improvement. However, community care, continuing care, and secondary care show no clear improvement.
External integration shows improvement in access to primary care (61.1 per cent) and referral from primary care (57.1 per cent). There was no clear change in internal and external integration of services for any modality. In particular, there is no clear improvement in access to community and continuing care, or access to and discharge from secondary or tertiary care.
Voluntary Hospitals and others
The highest improvement in all elements was reported by the Private Sector followed by the Voluntary Hospitals although they are slightly shaded by the Non-Statutory Agencies for Governance.
Individuals’ Engagement: The engagement of individual participants by the VHs improved substantially in respect of input to local policy and practice and service and business plans, and decision-making scope, but shows little or no improvement in respect of relevance of given targets, clarity of given role and of accountability. In contrast, there was a major improvement in all aspects of engagement by the NSAs and PS.
Culture: There is little or no improvement in internal or public trust for the VHs, but also no substantial deterioration either. In the NSAs and the PS there has been considerable improvement (over 70 per cent). There has been clear and substantial progress in collaboration and cohesion (of all types) across these sectors (over 65 per cent).
In leadership style, VHs report similar proportions of democratic, transactional/managerial, and autocratic corporate styles (27 per cent, 24 per cent, 27 per cent).
NSAs report autocratic style 50 per cent, while PS report nil autocratic and instead 57 per cent democratic. The immediate supervisor style is predominantly democratic across all these sectors. Transformational leadership in the non-HSE sector averages 6 per cent.
Centralisation and prescription has increased in the VHs and NSAs. In contrast, the PS are slightly more decentralised and empowered. This resonates with financial authorization, which is indicated in budgets assigned for VHs to 62 per cent of managers, NSA 87 per cent, and PS 100 per cent. Assigned budgets of €10million and over is indicated for 29 per cent in VHs, 47 per cent in NSAs and 56 per cent in PS.
Governance: This improved solidly for example structural and lateral role relationships, with great improvement in quality approach, clinical governance and service governance.
Functions: All Functional operations (systems and performance) improved substantially over all these sectors. Resource capacity currently available shows no net change overall. However, within this broad indicator there are still major concerns about the availability of financial and human resources, especially at upper management levels in the voluntary sector.
Performance management: This improved across all these sectors. It included shared goals and agreed targets and corporate accountability for them, with great progress in standards, indicators and measures (80 per cent). Coverage of diverse perspectives in performance indicators showed solid improvement (70 per cent). Planning cycle showed clear improvement over all items (mentioned earlier) eg monitoring and information availability, involvement of relevant parties, and availability of substantive choice.
Quality and Performance Improvement: Voluntary Hospitals and Private Sector lead significantly on internal quality improvement activities (64 per cent-100 per cent), and also to a lesser degree in respect of external activities. Performance improvement recorded substantial improvement across these sectors (66 per cent-76 per cent).
Organisational communications with patients has distinctly improved
National Services: Overall, perceptions of national care categories distinctly improved, as did both primary and tertiary care, but community and continuing care and secondary care show little or no change. Furthermore, integration within and between modalities shows little or no improvement.
A summary of the approach is included in the web version. Further findings of this research project will be published in due course.
Stiofan de Burca is Professor of Health Systems at UL
Peter Williams is Lecturer of Operations Management and Supply-Chain Planning,, Department of Manufacturing and Operations Engineering UL