Quality can’t work in a vacuum. That’s the message of a review study conducted by Anam Parand, PhD, and associates, out of the Imperial College London, who looked at 19 studies on the role of managers, leaders, and boards in quality improvement and patient safety and how that trickled down to actual quality of care and outcomes.
The findings are probably not hugely surprising — the programs that are the best at providing dedicated personnel, leadership/managerial time, and resources for quality work get the best results; those that give quality lip service do not. But Parand and his colleagues were interested in finding empirical proof of intuitive thought.
“You may well have a good idea of what hospital boards are, or should be, doing for quality partly because there are so many anecdotal commentaries postulating on it,” he says. “But this review presents only those study findings that report empirical evidence for these, and there aren’t many of them. In fact, one of the most surprising findings was the scarcity of such articles available globally to help advise managers at varying organizational levels.”
He’s had a lot of interest because of that, Parand says. “Managers and quality professionals want to know what the evidence says is currently happening and what is worth doing.”
The group of researchers was surprised to see some studies couldn’t prove a benefit between quality and safety and managerial actions — you’d like to think that any action thought out enough to merit a study would have some good impact. However, “there were a couple of studies that showed managers’ involvement to have a negative effect on quality-related matters, while others found no effect at all,” he says, noting that those particular studies may be anomalies, or they could represent bad ideas of intervention. “Of course it’s difficult to make such judgments with so little data to go on.”
The cool thing is that for those studies that have been validated, quality professionals now have some proven work to mimic. Among the best ideas, according to Parand: having a board quality committee; making sure the board has a quality report every meeting; keeping a dashboard that has national benchmarks noted on it; and rewarding staff for quality achievements.
“In our article, we present a quality management input-process-output model to show the conditions and actions that affect quality performance,” Parand says. “Basically it shows what managers are presently doing for quality and safety and where they can make an impact. More research would strengthen this model, so at the moment I would say that recommended approaches should be taken with an understanding of their limited substantiation.”
He’d like to see better research on what managers should be doing to have a positive impact on quality of care. “Our review has identified many gaps in the present research literature,” he says. “The ideal research study would address these weaknesses by including objective quality and safety clinical outcomes that are linked to actions performed by managers. The emphasis should be on actual actions rather than contextual factors alone, as has been the case in many of the previous studies. The over-reliance on participant reports could also be strengthened by supplementary methods such as observations.”
He’d like to consider reports from outside the English-speaking world, too, and to look beyond the boardroom, which seems to be the focus of most of the research. He’d like to see researchers look at frontline and middle management, “who are rarely considered by researchers, despite the large number of them.” Still, he acknowledges that “because of the complicated nature of managerial work and quality of care, it’s not an easy topic to research scientifically.”
The study can be found online at http://bmjopen.bmj.com/content/4/9/e005055.full.pdf+html.
For more information, contact Anam Parand, BSc, MSc, PhD, Research Associate in Psychology, NIHR Imperial Patient Safety Translational Research Centre, Imperial College London. Email: [email protected].
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Parand A, Dopson S,Renz A, et al. The role of hospital managers in quality and patient safety: a systematic review. BMJOpen 2014;4:e005055.doi:10.1136bmjopen-2014-005055.
