Policy Research Programme Summary Final Report Form

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Project Reference: 025/0062 Page 1 of 6

Policy Research Programme Summary Final Report Form

1. Project Details

Project Title: Organisational Culture in the NHS: A feasibility study to measure the impact on Older People

Project Duration:

(months)

21 Original Contracted

End Date:

30 April 2012

Start Date: 1st August 2010 Revised Contracted End Date:

31 August 2012

2. Grant Holder’s Details

Title: Dr

Surname: O’Mahony Forename: Sinead

Department: School of Medicine Role in project: Chief Investigator

Institution: Cardiff University

3. Keywords

Please provide up to eight keywords that relate to the research undertaken in this study.

hospital care, quality of care, older people, organisational factors, organisational culture, quality measures, excellent care, poor care, neglect

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4. Executive Summary

Please provide a structured summary which outlines the aims and objectives of your work in relation to the questions being addressed, the research design, the methods of investigation and your findings and conclusions. In addition, please describe the expected influence/impact of your work on the relevant policy field, service providers and wider stakeholders, and on current practice. Please ensure that this is a comprehensive, stand-alone summary of your work.

Introduction and aims of study

The quality of care of older people in institutional settings in the NHS has come under scrutiny following recent high profile cases. Measuring quality of care is essential for driving improvements in clinical practice and preventing abuse and neglect. The aims of this feasibility study were to:

 Determine what patients, their family, hospital staff and managers understand by good and poor quality care (as well as the extremes of excellent care and abuse or neglect) of older people in a variety of NHS hospital settings.

 Identify organisational factors that promote high quality care of older people and relate organisational culture to individual patient experience.

 Examine the feasibility of developing an index of organisational fitness to deliver high quality care that could be used within and across hospitals to drive improvements in the care of older people.

Background to study

The quality of care of older people in NHS hospitals has been subject to increasing interest in recent years. Measuring quality in care is essential for driving improvements in clinical practice and preventing harm. Organisational culture is central to promoting and delivering good quality care.

It is equally important and challenging to measure excellence in care, including quality of communication, respect for patient autonomy and choices, as it is to document risks and potential harms to patients. An overprotective environment can be harmful in promoting custodial rather than rehabilitative care. This project explored what is meant by excellent versus poor care of older people in hospital, the factors that determine quality and how best to measure quality of care, from the perspective of different stakeholders.

How the study was conducted

This project sought to learn from organisations with high standards of governance. Semi-structured interviews and non-participant observation were undertaken in 4 hospitals in England in 2012.

Interviews were undertaken with older people recently discharged from hospital, ward staff and senior managers. Non-participant observation was undertaken to gain an understanding of the environment and culture on nine hospital wards. Focus groups with geriatricians from across England and Wales explored how best to measure quality of care of older people. Data were analysed using thematic analysis.

Findings

‘Do we know what good looks like? Excellence in the hospital care of older people’

This study explored what is meant by excellent hospital care from the perspectives of service users, ward staff, managers and geriatricians. There was consensus about the equal value of outcomes of care and the intrinsic value of care processes and components. Achieving good quality clinical outcomes, ensuring access to hospital care in an efficient and timely manner and providing care appropriate to the needs and wishes of individual patients are all important aspects of effective care.

Clarity about excellence should help provide direction to services. The data were rich with examples of how to deliver excellent care. Strategies to help staff deliver person centred care include getting to know the patient, personalising care, promoting patient identity, involving patients in their care decisions through choice and flexibility, putting the patient at the centre of the organisation.

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‘Poor care of older people in hospital.’

Even in good organisations care is commonly inconsistent. All research participants described abuse and neglect of older people in hospital in terms of failures in service provision: failure to meet fundamental needs, psychological and physical; inadequate communication; poor access to care;

fragmented care and social & health care disconnect; delays in discharge; inadequate assessment.

Commonly financial and human constraints underpin failures in service provision. Human resource constraints included inadequate staffing levels on wards, hospital staff lacking appropriate training in the care of older people, undergraduate curricula not preparing doctors and nurses adequately, poor staff morale, inadequate staffing levels in wider health care community including social services. Such constraints could be considered a form of abuse/ neglect of older patients at the level of the organisation/ system.

‘Organisational factors that lead to positive and negative patient experiences.’

Key themes that emerged from the analysis of the perspectives of different stakeholders on organisational factors were the importance of leadership at ward and corporate level and by individual clinicians, organisational learning culture, internal and external team working, capacity and resources, competing values within and across the organisation, policy drivers and organisational milieu. Staff morale as well as staffing levels were considered important to the quality of care patients receive. The physical environment was found to relate to quality of care of older people in supporting dignified care and facilitating social interaction between patients especially at meal times. Single rooms have both advantages and disadvantages for older patients.

‘Assessment for Quality rather than merely of Quality’

Sustained quality improvements achieved through measuring quality of care internally within organisations were identified. Risks of measurement also emerged, including creating a tick box culture, distorting and/or displacing care, depersonalising patients and care, misuse of information and staff can become demoralised. Adjusting for case mix is a challenge when measuring quality of care and outcomes for older people, so process measures particularly those that predict long term outcomes are equally important. Outcome measures believed to reflect quality of hospital care of older people, included mortality rates, hospital readmission rates and appropriateness of care home admissions.

Obtaining good quality data needs investment. Organisational factors underpinning quality important to measure include staff expertise and seniority, staffing levels, sickness rates and vacancies and audit/governance arrangements. Quality of care measures need to be multidimensional spanning all domains of quality, timely and linked with feedback to staff. Measurement methods should be multi- modal, with multiple sampling, and should capture omissions in care and reflect and support core values in the organisation.

Key messages

 Organisational culture is complex and multiple subcultures coexist in one organisation. Hence, global ratings of care are over simplistic.

 Outcomes, processes and components of health care are all equally important aspects of excellent versus poor care of older people. Good quality outcomes contribute to excellence but outcomes alone do not define excellence.

 Anticipatory or proactive care is central to excellence at the level of individual patient assessment, risk management and planning, as well as at ward and institutional level in terms of policies for the older person and adequate training and education of staff.

 All stakeholders described abuse and neglect of older people in hospital in terms of failures in service provision, underlining the need to measure omissions in care.

 Competing values both within and across organisations can detract from patient centred care and distort care particularly when external drivers or targets dominate.

 A learning oriented culture focused on patient experience and safety with strong clinical governance structures and the ability to respond quickly to a problem are key to good patient experience.

 Measurement must be timely and link with feedback and actions if it is to lead to improved care.

 To minimise the risks of distorting care and unintended consequences, assessments need to

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be multi-dimensional. All domains of quality need to be assessed, including process and outcome measures and patient experience, as well as safety and organisational factors underpinning quality.

Implications for policy and practice

All healthcare providers should pursue excellence in the health care of older people across all 3 domains- outcomes, processes and components of care.

Organisational culture is complex and global ratings of health care are over simplistic. Quality assurance measures must reflect the complexity in older people’s care, be multi-dimensional, multi- modal and link with actions to drive up quality.

All undergraduate and postgraduate training should prepare health care staff for competing demands in the workplace, foster a culture of patient centred care and address the needs of older patients.

5. Lay/Plain English Summary

The Department of Health actively encourages the dissemination of research to the public and it is therefore essential that you make the content of your summary and the implications of your research accessible to lay persons. Please provide a plain English summary of objectives, findings, and conclusions of your research, avoiding both technical terms and undefined acronyms.

Investigations such as that into the Mid Staffordshire NHS Foundation have highlighted sub standard care and neglect of older people in hospital. It is important to measure quality of care of older people, so we can improve care and prevent abuse and neglect of older people. It is equally important to measure positive as well as negative aspects of care, to come up with a balanced picture to help drive improvements in high quality care.

Patients, carers and staff on selected wards in four hospitals in England were interviewed to find out what people understood by excellent care and the factors that determine quality of care of older people in hospital.

We also observed care on hospital wards in these Trusts and examined organisational factors that promoted high quality care.

Findings

‘Do we know what good looks like? Excellence in the hospital care of older people’

The effectiveness of care in achieving good clinical outcomes, good communication and patient experience, and certain approaches to care (being patient centred, anticipatory and restorative) were found to be equally important in contributing to excellent hospital care of older people. Clarity about excellence should help provide direction to services.

‘Poor care of older people in hospital.’

Even in good organisations care is commonly inconsistent. All research participants described abuse and neglect of older people in hospital in terms of failures in service provision: failure to meet fundamental needs, inadequate communication and assessment, poor access to care, fragmented care, delays in discharge.

Commonly resource constraints including inadequate staffing levels and training underpin failures in service provision.

‘Organisational factors that lead to positive and negative patient experiences.’

Leadership, teamwork and the ability of an organisation to learn from mistakes are key to delivering good quality care. Staff morale as well as staffing levels were considered important to the quality of care patients receive. The physical environment was found to relate to quality of care of older people in supporting dignified care and facilitating social interaction between patients especially at meal times

‘Assessment for Quality rather than merely of Quality’

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Several examples of measurement being used to drive quality improvement were found. Risks of

measurement also emerged, including distorting, displacing and depersonalising care. Outcome measures believed to reflect quality of hospital care of older people, included mortality rates, hospital readmission rates and appropriateness of care home admissions. Adjusting for case mix is a challenge when measuring outcomes of care for older people, so measuring processes of care and organisational factors underpinning quality are equally important. Measurement needs to be timely and linked with feedback to staff to drive quality improvements.

6. Details of Patient and Public Involvement in the Research

The Department of Health supports the development of an evidence base for patient and public involvement (PPI) in research and is therefore keen for researchers to record, learn from and share their experiences of PPI in research.

Please provide a structured summary that:

 Details the PPI undertaken in this research project;

 Describes how, if at all, this has differed from what had originally been planned and why;

 Considers what impact, if any, PPI in the project has had on any aspect of the research process and outcomes;

 Reflects on the key lessons learned (both challenges and successes) from the process of PPI in this project.

If you did not have any PPI in the project, please explain why.

Discussions were held with groups of older people and their relatives or carers to discuss approaches to data collection, recruitment strategies and piloting interview schedules. This enabled the research team to benefit from a comprehensive input by service users and their experience in the design of the study.

7. Addressing Equality and Inequality

As set out in the DH Research Governance Framework for Health and Social Care 2005, research and those pursuing it should respect the diversity of human culture and conditions and take full account of ethnicity, gender, disability, age and sexual orientation in its design, undertaking and reporting. It is particularly important that the body of research evidence available to policy makers reflects the diversity of the population. Please describe how this was addressed in the planning and delivery of your research, and what contribution your research will make to informing policy to tackle inequalities in health and/or social care. If diversity was not explicitly considered in this piece of work, please explain why.

This study had clear participant inclusion criteria ( 65 years or over, 4-8 weeks post discharge from hospital, cognitively and linguistically able to participate in interview, able and willing to give informed consent), and at no point were any other factors considered with regards to inclusion or exclusion.

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8. Key Publications and Presentations by the End of the Project

Please list here any publications which have resulted from this piece of work, including those currently in press. This should include journal articles, conference proceedings, press releases and all publications in the lay and scientific press, including website links to published articles if appropriate.

Author(s) Title Reference/Further Details

Hunt, J. Sanchez, A.

Tadd, W. O’Mahony, S.

Organizational culture and performance in health care for older people: a systematic review

Reviews in Clinical Gerontology August 2012; Volume 22. Issue 03: pp 218-234