Editorial
Article Type:
Editorial
From:
Leadership in Health Services, Volume 26, Issue 4
This issue may well come as a surprise to some people because you will notice it includes nine articles instead of the usual five. The reason is an amendment to our pagination system so that we have some flexibility to add more articles if needed. This new variability is of especial benefit to authors because it will serve to reduce the wait time between final acceptance of a manuscript and actual publication. We will not always be including nine articles in an issue, this is not a precedent, but it does allow us to move through our waiting list of approved articles faster. We anticipate that the new policy will be pleasing to our contributors who have let us know their frustration with the somewhat long publication wait times they have had to contend with. At the moment, we are watching how things work out, but hopefully it will be of benefit to all parties.
Sometimes our Editorial Board Members are invaluable. This is certainly the case with Michael Ahern who pointed out some serious inconsistencies and factual errors concerning a previous editorial I wrote for Issue 26,1. Thank you, Michael for your feedback. Since your work was some of the inspiration for the original editorial, it is only fitting that I pay attention to your observations.
According to Michaels information, it is generally accepted that seven persons were killed as a result of the E. coli outbreak in Walkerton in the spring of 2000 (not the 11 I noted). Further, and sadly, Michael notes that 2,300 people were made acutely ill as a result of the contaminated water. This is no simple disease and one of the survivors, Jeff Holliday who spoke in an interview with Anna Maria Tremonto on CBC radio, was tragically very close to death as of April 1 of this year when Michael wrote to me. You can listen to the interview at: www.cbc.ca/thecurrent/episode2012/10/03e-coli-outbreakin-alberta-remembering-walkerton/ I did hear Jeffs interview and was profoundly moved.
Michael also commented on the type of contamination which was much more than just Ecoli. According to Bruce Davidson – a co-founder of Concerned Walkerton Citizens – the water in Walkerton was found to be contaminated with a cocktail of pathogens, including E. coli 0157:H7 and Campylocbacter jejuni and Giardia. The enormous long-term chronic illness impact on the community as a result of this incredible lapse of safety protocol cannot be underestimated. It is why we can never take our public health system for granted and must always demand of our leaders, both political and managerial, the best possible standards for the infrastructures and safety and inspection practices of on which our health depends.
The beef contamination at the Brooks plant which was the main subject for the editorial is no longer an issue in this province – thankfully. There is new ownership at the plant, and new government, managerial, and inspection processes have been implemented, according to news reports. But every day there are reports of just how close we are to public health disasters – whether it be at the larger level through the terrible spring floods we have just experienced here in southern Alberta, a train loaded with fuel almost collapsing on a bridge over the Bow River just after the flood, or a huge train/fuel explosion in Quebec – all are major threats to our most precious life resources –food, water and air. They pinpoint just how fragile the services that determine our health really are. They remind us that the business processes and procedures we value and apply to our commercial lives are not always applicable to the institutions that are generally held to be responsible for our societal health and well-being. They persuade us to ask the question – “what is leadership? Is it the stuff of efficiency and money saving, or can it be more human and inclusive? Here in Alberta, our provincial government recently fired an entire provincial Health Board, which it had originally appointed to bring about increased efficiencies and cost savings in the system. Why was the Board fired? Because its members claimed they had met their cost saving targets and as a result were contractually entitled to millions of dollars in the form of bonuses from the same government which had appointed them to cut costs. Simultaneously, this same government had just announced a huge revenue problem which is seriously impacting all services, especially health and education. It is surely bad optics when the health service you are trying to run is constantly in need of more money, when people who work at the lowest levels – in long-term care and home care – are being laid off, yet at the same time million dollar bonuses are being claimed by those at the top because of the efficiencies they claim to have brought about. The model would seem to be flawed. It is a paradox that profit oriented business leadership does not always equate with human leadership. The two paradigms are at odds with one another, and the victims are always those most vulnerable –those in smaller communities, the employees at the bottom of the ladder, the sick and the elderly, not to speak of the tax payers who ultimately end up paying for everything – including the bonuses!
This topic is obviously something I as Editor, feel strongly about. It is also a perfect segue into the first research paper in this issue – by Dr Deon Canyon entitled “Pre-crisis damage containment and leadership policy in health services. In this article, Dr Canyon investigates damage containment mechanisms in the form of physical processes and strategic decisions aimed at limiting physical and social damage specifically as they apply to health organizations. He asks a sample of senior decision-making executives from randomly selected health organizations in Australia about their systems of damage containment and back up mechanisms to deal with crises. His findings are somewhat surprising, in that the majority of health organizations lacked sufficient Damage Control Mechanisms to deal with crises and indeed, if they assign risk, it is only after a crisis has been experienced (like most of us!). Indeed, he notes that damage control mechanisms are generally neglected by top management and that a more “proactive preparedness culture could be attained “by ensuring that efforts to monitor and control damage are properly aligned with different types of crisis. In an age of increasing global pandemics and disasters, it would seem that we need more research into the need for this kind of preparedness and the involvement of top management.
A second paper in this issue speaks to the need for peace making to be built into the educational curriculum for medical practitioners in training. Authors Courneya et al. note that physicians can play a role in reducing conflict through their uniquely privileged social status, and in helping to heal violence-ravaged communities. The authors explore how medical education can be designed to support peace keeping mechanisms and have conducted qualitative research through literature reviews and interviews with various knowledgeable parties to address the question more fully. In some ways, the article reminded me of various lectures I have attended from members of Medecins sans Frontieres, but it also pointed out that medicine is not just the technical and mechanical discipline we usually assume it to be. It serves to remind us that even here in medical education, a more holistic view of community and people is creeping into the body of knowledge and the education that supports it.
Two articles address the need for a more caring approach both for nursing directly and in the mostly not for profit organizations providing community and aged care. Alistair Hewsons fascinating article entitled “The missing leaders: rediscovering the Ward Sister/Charge Nurse role is really a call for bringing back the role of Matron in a new form specifically to lead nursing care which has been under increasing criticism, particularly in the UK. Using Henry Mintzbergs model of blended care, he suggests the Ward Sister can manage the nurses under her as an extension of the caring practice she extends to her patients. Managing as blended care has both cultural and educational ramifications, but generally if such a key role is adopted for Ward Sisters in countries other than just the UK where the model originates, it could do much to strengthen patient care which has suffered in recent years. In somewhat similar vein, Kelly Shaw examines the competencies that senior managers responsible for aged and community care in Australia believe are required for effective leadership. Some of the participants in the study came from faith based agencies, others from non-profit or senior government departments or agencies. Her research takes note of the perception of clients that not-for-profit faith based agencies will, because of their ethos, reinvest profits into care improvements. Such expectations create tension for leaders who not only have to provide care for clients but also must meet the service delivery expectations of stakeholders and ensure the business operates on a sustainable basis. Once again, we are reminded of the paradox between the business and the caring ethos.
Three articles in this issue concern efficiencies in the health system using Lean Six Sigma methodologies. I am always amazed at the amazing results that these kinds of methodologies bring about, in terms of practical benefits to hospitals. For example, Laureani Alessandro describes how the implementation of Lean Six Sigma technologies by masters degree students relatively new to lean concepts, in an Irish hospital, was useful in many different areas of a hospital for purposes of streamlining stores operations, redesigning work processes and monitoring project effectiveness. Alessandro notes the importance of leadership, both at the top and at the departmental managerial level, to support these kinds of initiatives.
Researchers Gijo, Antony et al. in their paper demonstrate how Six Sigma methodology has been used in a Pathology Department to specifically reduce patient wait times. This they succeeded in doing with an average wait time reduced for patients from 24 minutes to 11 minutes. They note that for their particular hospital, the implementation of Six Sigma for process improvement was a first, and required training for technicians and nurses to learn about statistical analysis and the use of statistical software, as well as an understanding of the value of data based decision making. This certainly contrasts with the usual topics provided for nursing training such as medicine, hygiene, housekeeping and so on, and was initially viewed with some suspicion.
Finally, Andrea Chiarini provides us with a case study from an Italian hospital concerning waste savings in patient transportation using Lean Thinking tools and logistic solutions. As Chiarini points out, her paper has strong implications for practice. Using some of the tools specifically adopted from Lean Thinking, many costs can be analysed, specifically those related to patient path and transportation, demonstrating wastes in terms of wait times and queues. Not only do the results demonstrate significant cost savings, they offer different ideas for hospital layouts, and also have significance for reducing the number of hospital generated infections.
The final two papers offer a different perspective on service and management. First, William Johnsons article discusses how to measure hospital out-patient service quality in Thailand. Johnson, using dimensions from SERVQUAL, demonstrates the importance of empathy as a dimension of service quality enhancement. Other qualities include flexibility in working hours, visually appealing decors, and assurance including reliability of service. Johnson suggests using this model to explore additional avenues related to health care services and their quality. It should be noted that the SERVQUAL methodology is increasingly being used in medical settings, rather like LEAN and SIX SIGMA, and may well provide a useful tool for assessing dimensions of care.
In contrast Elisabet Hoog provides us with a qualitative research paper in which she explores the challenges of managing a multi-sectorial health promotion program in Sweden. She writes that the management teams, one strategic and one operational, representing two autonomous programs, identified some important issues that affected all, but lacked a shared mental model of the situation revealing variations in key characteristics and in perspectives on solutions. Her study suggests some methods for bringing about shared mental models of goals, roles, and responsibilities so that they can become a foundation for coherent support of change and direction. Her research reminds us that leadership and management must always address the issues raised by the ever moving constants of differentiation while struggling to maintain integration through shared vision and purpose.
These nine articles represent a variety of snapshots of issues impacting health service, and the concerns and opportunities they represent. We hope that our new and more relaxed policy around increased pagination will serve as a greater motivation to submit your research and share your knowledge in this dynamic and ever moving field of health service leadership.
Jennifer Bowerman
