Want more bang for your quality buck? Get strategic! Pursue point of care quality 'from top floor to shop floor'.

I've written countless quality-related articles and posts over the years. But although they explore quality and clinical governance from different angles, they all focus on the same conundrum: how do we create consistently good care within the complexity of human services?

Turns out you can! - but it requires a particular mindset. It's the thinking you see in high-performing organisations; those that know exactly what they're trying to achieve, and are focused, aligned and driven - from 'top floor to shop floor' - to make it a reality.

Why is a different mindset required? Why don't quality and clinical governance systems just provide more bang for buck? My pursuit of the answer to this question led me to develop the 'strategic quality system model' about 10 years ago. The model is based on my own and others' research - and working with thousands of boards members, executives, managers, staff and consumers across all human service sectors - and testing implementation in many organisations since then.

Bottom line - all the research evidence and feedback from human services agrees: high-performing human service organisations believe that great care is created by great people, supported by great systems. Common sense? Yep - but common sense isn't always common practice.

Here's a short model explainer video: https://vimeo.com/cathybalding/qsystemessentials?share=copy

Books, video courses and resources explaining the logic and research behind the model and implementation steps: www.cathybalding.com

Why a strategic approach?

We tend to focus on the clinical governance systems we're given to work with - such as standards, measures and other compliance requirements - and 'hope' that by ticking those boxes we get satisfied staff supporting consistently great care. But 'trickle down' clinical/quality governance doesn't get us very far in the complex human services world. We must be crystal clear about what we want to achieve or it gets lost in the maze of complexity.

What does a strategic quality system look like?

The system works in three parts:

A. Desired point of care quality is clearly defined with staff and consumers. Having been through this proces with thousands of people over 10 years, I can report that what human beings want from a human experience doesn't vary across sectors. They want:

*to be treated like a respected individual (receive 'individual or personal' care)

*kept safe from care-related harm (safe care)

*to know the dots are joined so they don't slip through the cracks (connected care)

*that the care is right for them and achieves the best possible results (effective care.)

Every other dimension of quality care model fits somewhere in these four goals for great care (eg, 'accessible' fits in 'connected' care; 'equitable' fits in 'personal' care.) Four goals is enough for people to remember, and doesn't over-complicate what we're trying to achieve. Importantly, - each of these can be influenced by staff and managers every day (and therefore the process of defining these with those who will work with them can't be skipped - this is where the missing links of meaning and sense-making are introduced.)

The 'how' this is achieved is where sector variance comes in; for example how you create safe care in an operating room vs in an aged care setting will be different. But 'safe' care is equally important in both. (Yes - we are all 'different' - but the differences lie in how we achieve good care. What people want from a human service - the goals for good care - don't vary.)

These goals are linked to the organisation's strategic plan aspiration about how good the organisation wants their care to be - and so brings in the board role of overseeing the pursuit of the four goals as a strategic focus, and therefore an operational focus for the executive.

B. A focus on the biggest influence on how consumers experience care and services - managers and staff. This is about equipping them with the right role clarity, knowledge and tools to achieve those four quality goals with consumers - and supporting them to improve their job satisfaction in the process. If consumer and staff satisfaction are not addressed as interdependent, we'll still be having the same 'how can I engage staff in quality?' conversations in 10 years.

C. The quality and clinical governance systems - externally mandated and internally developed - that support good care. This is often where we start, but it's really the final piece of the puzzle. First, we must know that everyone is on the same page - from top floor to shop floor - about what we want to achieve at point of care. Does this make sense to staff and do they feel supported to pursue this every day? Then we can ask - how can we make the systems they must work with supports for achieving consistently good care, rather than barriers?

We have systems for measurement, reporting, responsibility, managing clinical risk, credentialing, partnering with consumers, improvement and supporting care delivery, to name a few. But just having those systems in place is not enough to carve through the complexity maze with maximum point of care impact. This is like dumping a whole recipe of clinical governance ingredients into a bowl, and hoping staff can create a great quality care dish out of it. Consumers may get fed, but the quality of the meals is going to be variable day to day.

Systems are only as good as the degree to which they help staff to create consistent quality care as part of their daily work - ie, to create a quality cake they want to make with consumers. This means that implementation is designed, not to make life harder, but positions clinical governance systems as purposeful and useful tools for managers and staff to achieve the quality goals with every consumer.

Too often, quality and clinical governance systems are implemented first, and then staff must fit their work around them. This is a key reason for lack of bang for buck for all the work done in the name of quality improvement and clinical governance. There's no point having beautiful ingredients lined up if those mixing the cake don't know what type of cake they're making, and aren't even sure if it's worth the trouble. This approach does not produce a consistently good quality care cake.

Build on what we have - but with renewed purpose and mindset

We have all the tools and systems we need for consistently good care - we don't need more. It's the way they're implemented that makes the difference. Despite the real and significant challenges of lack of staff and resources, many problems with poor quality care and staff dissatisfaction stem from things we can control: focus, purpose, meaning, sense-making, support - these cost nothing and yet make a significant difference to how the 'quality care cake' comes together at the table for consumers and staff.

Ultimately, the quality of care and services comes down to the interactions between staff and consumers. If we don't make clinical governance systems a means to achieving a defined point of care purpose that is good for consumers and staff, I fear we'll be having the same conversations in another 10 years, with lots of variable 'quality care cakes' in between.