Editorial

Article Type: Editorial From: Leadership in Health Services, Volume 23, Issue 3

One of my favourite monthly newsletters is the Gurteen Knowledge Letter– a letter containing many titbits of information about knowledge management from around the world. One item that particularly struck me in the March edition was entitled A Colossal Knowledge Management Failure. Written by Ron Donaldson and based on two articles from the Sunday Times dated March 8, 2010 the author points out that the blind pursuit of management targets in complex systems such as health and education has been a huge failure leading to nothing but negative results. “Ongoing introductions of outcome measures have done little but achieve ongoing dissatisfaction amongst staff and result in a lack of trust yet despite the lack of results, our leaders still adhere to these flawed management policies”.

My question therefore is how much do we have to know before we actually bring about change? Could it be that the emphasis on targets – and other managerial and business fads of the day have not only failed, but, actually caused a lack of leadership? Is leadership sufficiently involved in leading change and bringing it forward into the long term? In short, does Donaldson’s thesis not only represent a failure of knowledge management but also a failure of leadership?

I would like to think that our leaders are doing their best, and truly understand the problems, but I realize that once people are in the health field,the traditional business of sickness that dominates the system takes over, the complexity becomes overwhelming, and it is difficult, if not impossible, to introduce new models and ways of doing things that require time. It is tempting to think that the quick fix, flavour of the day models that appear to have been successful in the business world could also be of benefit here.. However,seductive as the business models may be, Ron Donaldson points out, in the end they do little to bring real change to the system. We know they don’t work,yet we still keep on using them.

The question of how much knowledge we have to possess before we can implement what we know through action and thus make lasting change became very real to me at a recent healthcare workshop I attended. Speaking to us was a couple of senior bureaucrats from my own province discussing our provincial health service and the difficulties they faced in terms of leaders responsible for effective decision-making.

In Alberta, it was quoted, we spend 33 million dollars a day on health services, not including physicians’ fees – and we are one of the richest provinces in Canada. These costs are continuing to rise. Our provincial healthcare system, like most of the others in the world, is anchored in the investments of the past – mostly buildings in the forms of hospitals. When these buildings were first built, they were the pride and joy of the communities where they were located. Now they are obsolete. In addition, people are slow to change. They fail to understand the enormity of change that is happening in health care today. Therefore, instead of our province being able to invest more in wellness programs, which are the only way to reduce costs in the long run, we still have to invest way too much in acute care – which as the other systems we should be investing in become overburdened and depleted –becomes a very expensive dumping ground These other systems include primary care, public health, and long term care. The fact of the matter is that the rapidly changing demographics – especially around our aging population,means that individuals with chronic conditions that could be treated locally if only the appropriate local facilities were available, end up in the acute system, thus spiraling the costs ever upward.

In addition, we heard that most health care procedures are based on preferred modes of operating, even when there is evidence to suggest that newer and cheaper procedures are available. Hence, new equipment and technologies are introduced to medical settings in the interests of change and effectiveness even when the old ones they are intended to replace are still present. Even our billing codes are outdated – over 40,000 of them exist, with no established ways of eliminating the old ones even as new ones are introduced regularly.

These then are just some of the issues in our health services faced by our leading administrators and politicians. They are all too familiar to everyone who works in a publicly funded health care system. We know better, we have the knowledge for change. Yet for some reason we are unable to reduce this ever-spiraling cycle of increasing costs and inefficiency? We are unable to stop our investments in the obsolete components of the past and invest sufficiently in the future. The pressures of the short term and the political need to please people who are reluctant to change are just too strong.

In summing up my editorial leadership message here therefore, my questions are:

• 1.

  How much knowledge, do we as individuals, and organizations actually need before we listen to and work with leaders to change our ways?

• 2.

  Are the problems and pressures created by the past just too great for leaders to implement effective change especially in systems as complex as health?

• 3.

  How do we persuade our leaders to make the time for ongoing development of people working in the system to develop their own leadership capabilities without imposing on them artificial business models designed for a different business paradigm?

The five articles included in this issue, although not so encompassing as these themes speak to the increasing global reach of our journal and speak to a variety of issues increasingly important in health care.

How well do business models apply to health care? Amy Grove et al.discuss this very subject in her study of Lean Thinking as a means of reducing costs and increasing efficiency in the NHS’s Health Visiting Services. Lean of course is the model that Toyota made famous and has become popularized in management literature. There have been many successful applications and the lean model has been applied to a number of health care situations with some positive results. Grove et al. point out that lean has its critics – there have been findings that the system leads to limited creativity a reduction in innovative thinking and higher stress levels. As I write this editorial it should be noted as well that Toyota’s reputation in the automobile industry is no longer as pristine as it once was which may lead to further criticism of the lean model.

Groves et al.’s eminently readable research article will be of value to those interested in the lean application to complex human environments such as Health Visiting Services. The method may well have promise as a method of reducing costs and increasing service, but her research demonstrates that to work, it requires considerable planning and considerable communication in terms of the complexity of the circumstances it is being applied to.

Gary Blau et al.’s research uses leader member exchange theory at a hospital in Oman to assess how organizational sportsmanship can build greater organizational effectiveness. They define sportsmanship as discretionary behaviour that is willing to tolerate the minor inconveniences of organizational life without complaint and notes the importance of the subordinate/supervisor relationship to promote positive outcomes in the workplace. Given how stressful working life in a busy healthcare environment can be, his research may well have training and learning implications for those who wish to build more positive workplaces.

The next two articles relate to health care in Jordan, a country we have not published from before. Muayyad Ahmad et al.’s contribution evaluates the quality of life of patients with different types of cancer in Jordan and its relationship with nursing care. Their finding that nursing care that concentrates on the patient- especially for cancer patients can improve their quality of life is important. When we have friends with cancer who rave about the quality of nursing care they receive, we tend to take such information for granted. It is gratifying therefore to read research demonstrating the importance of this care.

In Jordanian hospitals as well, Dr Ababneh writes of the importance of organizational culture, particularly as it applies to innovation to help build quality improvements. His study not only recommends longitudinal research but also comparative research to test the applicability of his findings outside of the Jordanian context. Organizational culture would seem to be an important springboard for organizational success. This research suggests that before introducing a quality initiative program, it would be useful to assess the culture of an organization, and through appropriate programs including training and development, build the culture first so that the quality initiative can actually have the desired impact.

The final paper is from Malaysia. Written by Dr Rosita Jamaluddin et al.,it assesses the bulk trolley system of food distribution in a Malaysian government hospital. The paper discusses the types of food and how to enhance food intake and reduce wastage. Hospital food is a subject of huge importance in health care, so it is a pleasure to be able to include this article which is not only important for the Malaysian setting but also offers a comparative perspective for those of us elsewhere in the world. It was noted by one peer reviewer that very few papers from Malaysia on the health care system had crossed his desk, so hopefully its inclusion fills an important gap.

These along with the Talking Heads interview complete this issue. As Editors we trust that you will find all these submissions of interest and that you will continue to help us build this increasingly global perspective on leadership in health services.

Jennifer Bowerman