No, 'everyone' is not responsible for quality.

Recently on a plane I pricked up my ears to this conversation - roughly paraphrased - going on behind me:

Passenger A: 'Bob's just out of hospital again.'

Passenger B: 'How is he?'

Passenger A: 'They stabilised him and changed his meds so he seems much more comfortable. Not sure I'll be able to convince him to go back there next time though.'
Passenger B: 'Really? What happened?'
Passenger A: 'Oh, you know, the usual. Nothing too bad - it's just that he's getting sick of it. They got his name wrong on the bracelet again and we had to complain long and loud to get it fixed. I know our name isn't the easiest to get right - but that's no excuse. Of course this meant that we had all sorts of fun and games with medications and tests - the staff listened to us even less than usual because half the time they thought Bob was someone else or they couldn't find him in their records. It's a miracle something didn't go wrong.

'And the staff - how good the care is depends on who's on. He even had a fight with the weekend physio this time. I don't know what that was about. There was the usual drama with trying to work out when he'd be discharged - this was really tricky for me - as you know I'm travelling all over the place for work at the minute. And I wasn't able to get in to see him every day because I've been away so much - and when I did, he didn't look - or smell - very clean - said he hadn't had a proper wash since he was admitted - but surely that can't be right. And the food!

'Anyway, it's a pain, because the clinical care is good, and it's close to home - but Bob is very unhappy with everything else about it. He thinks the sicker he gets, the worse they'll treat him as he won't be able to stick up for himself. I don't know what we should do.'
Passenger B: 'Have you talked to the GP?'
Passenger A: 'Yes, but she thinks that it's all fine because they manage his condition well - she doesn't understand how important all the other stuff is to him. Oh good - food.'

At this juncture, our snack was served and their conversation turned to airline food. (How was she rating the airline snack compared to Bob's hospital fare, I wondered? And how different is the relative importance of food in both settings?)

So, of course, I got to thinking...

Who really is responsible for what happens at point of care?

Some of you may be wondering if I've spent too much time at 10,000 metres. Isn't it obvious? Well, no, not as obvious as it needs to be. Some of you will say the board, some the CEO or clinical executive, some the department head and some the care giver. Trouble is, it's all of those people - and as a consequence, sometimes none of them.

What do I mean? As many of you know, I visit a lot of health, community and aged care services. I consider it a great privilege to have the opportunity to discuss safety and quality issues with boards, managers and clinicians, look at their data and review their systems. 

One thing always stands out for me about these visits: in general, boards, executives and staff are optimistic about the quality and safety of care they provide. Everyone wants to provide great care and services. And most services believe they do.  'Everyone's responsible for quality' they say proudly. Technically this is true.  But it's often said as if saying it makes it a reality;  everyone's out there playing their role, easily overcoming the challenges of complexity, culture, funding and politics to provide safe, high quality care for every person, every time.

This is where an interesting phenomenon that I call 'quality of care blindness' comes into play. We've become so fixated on key risks and other clinical KPIs, that we think the other ingredients to a great experience cake - Bob's issues - must be ok. And, hey, don't we have great staff? Of course they're out there every day meeting consumers' needs. What else would they be doing? In the absence of evidence to the contrary, what's the problem? Because we don't focus on, report on, endlessly monitor, present at conferences on, all the stuff important to Bob and Passenger A,  we don't know what we don't know: we have quality blind spots. 

So, back to who's responsible. I'm constantly banging on about great point of care being driven from the top of the organisation through line management to the bedside/chairside, with specific responsibilities allocated at each level, as many of you will know. Enacting these requires clearly described specific roles to be well supported. But where does the responsibility lie for making sure this is really happening in practice - and that consumers are better off as a result?

Do we need Care Leaders?

You might say 'the Quality Manager' - and maybe this was true once upon a time - but now they are completely absorbed in the mechanics of monitoring and reporting on key risks, clinical KPIs and standards. Is it the executive? Well, yes, it is - but even with the best intentions, how much time do they have to allocate to determining how well care is delivered, apart from reviewing the aforementioned risk and standards data? And if they do spot a problem, how good are our delegation systems down the line, to address the issue at point of care? And then to embed the improvements across the organisation? Each of these actions is a challenge - put them together and it's a big one.

'What about the service managers and point of care staff?' I hear you ask. Well, yes - and no. Most point of care staff think they're already doing a great job - as previously mentioned; and many middle managers will tell you that they're so busy with paperwork that they don't get out and about as much as they should. So their capacity to notice what's really going on, as opposed to getting through the day, is compromised, whatever their job description says about responsibilities.

Of course there are exceptions, where a comprehensive view of care is defined and embedded in every single person's job description; and staff are both supported in and accountable for delivering it. I salute these organisations for making 'care' an organisational priority - this is not an easy thing to achieve (consumer readers, I hope you're sitting down.) But 'Bob's' experience is still too common. Partly, I think the problem is that most health, aged and care services don't have a senior, wise, well respected clinician - a 'Care Leader'  - whose job it is to make sure that a comprehensive view of care is defined and enacted. Not detracting from the line management responsibility to design and deliver the care - but supportive of and complementary to it. 

Would this help in your organisation? Providing consistently high quality care in the complexity of health and aged care is an enormous challenge.  Leading this should come in many different forms and guises.