By Dr. Marcella McGovern, Change Team, ARCH
Earlier this month, RTE Investigates broadcast a programme called ‘Living on the List’, depicting the human stories and consequences behind Ireland’s lengthening hospital waiting lists. Furthermore, it revealed that hospital waiting lists are nearly 13% longer than previously reported (625,185 Vs 545,147), with the discovery that the National Purchase Treatment Fund (NPTF) maintain two additional waiting lists for “Pre-admit” and “Planned Procedure” cases, which were not included in prior “official” waiting lists published on the NPTF website (IMT, 9th February 2017). The Minister for Health, Simon Harris, responded to this programme by saying that he “intends to shine a light” on management in the Irish Health Service Executive (HSE) and that if management does not “measure up”, they will be removed from their roles.
This response reflects what Dubnick (1996) refers to as a prejudicial blame culture, which he describes as violating all three major conditions for an idealised model of blame. It isn’t clear that HSE Managers are: 1) responsible for the problem; 2) have caused or contributed to the problem or 3) have full knowledge of what the problem is. The Minister’s response may communicate to the public
|Dubnick (1996) Prejudicial Blame Culture:|
|Three major conditions|
1. It makes no requirement that the blamed person or collection of persons have assumed responsibility for the condition they are blamed for; rather, it targets an ill-defined but inclusive group that everyone knows to exist (e.g. bureaucrats);
2. It doesn’t require any role for the blamed in contributing to the cause of the blameworthy or harmful condition. It is assumed that the vaguely defined ‘they’ are highly influential in shaping the world;
3. [It] eliminates the need for any degree of specificity regarding what the harmful condition entails. It could be the decline of the economy, or the loss of national prestige, or the general malaise of society. (Dubnick, 1996: 22).
and the media that the Government acknowledges that there is a problem but it fails to acknowledge the Government’s responsibility for that problem. Governance, performance oversight and holding the HSE to account for the implementation of national health policy are key functions that the Minister for Health and his Department are responsible for performing on an ongoing basis; not in response to a crisis. The question put to Ministers for Health in a crisis therefore, should be where in your Department’s oversight of the HSE did you fail to detect this problem and what steps are you taking to correct the problem and ensure that it doesn’t happen again?
Paul Cullen highlighted in an analysis piece in the Irish Times (Irish Times, 11th February 2017) that Minister Harris’ predecessor, Leo Varadkar, similarly promised that “heads will roll” over hospital overcrowding. Yet, this winter again saw overcrowded Accident & Emergency Departments resulting in planned inpatient and outpatient appointments being postponed. The back-log of these postponed appointments are now contributing to the current crisis over long waiting lists, illustrating that unjustifiably “blaming the bureaucrats” (Dubnick, 1996) has knock on effects.
Digital Innovation & Organisational Culture
From a Connected Health perspective, there is a danger that a blame culture demonstrated at the highest levels of the Irish health system will have a trickle-down effect, compromising system readiness for innovation. If the Department of Health blame the HSE for poor management and the HSE blame the Department of Health for inadequate resources, and if clinicians blame managers for excessive bureaucracy and managers blame clinicians for resisting change; organisational trust may be lost in the battles between “us” and “them” (Firth-Cozen, 2004). Within such environments, potentially transformative leaders and early adopters behave cautiously and become reluctant to take “ownership” of innovations (Heitmueller et al. 2016), which by their nature carry the risk of failure and unintended consequences (Ash et al. 2004).
A recent survey conducted by MIT Sloan Business Review and Deloitte found that digitally maturing organisations – where digital technology has transformed processes, talent engagement, and business models – are integrating their digital strategy with their companies overall strategy. This survey was undertaken in 2015 with 3,700 business executives, managers and analysts across 131 countries and 27 different industries, including healthcare. It identified that digitally maturing organizations possess certain “digital culture” characteristics (see Figure 1). These include an expanded appetite for risk, rapid experimentation, heavy investment in talent, and recruiting and developing leaders who excel in “soft” skills e.g. transformative vision or being a forward thinker (Kane et al. 2016: 3).
Organisational culture change is more difficult in public service organisations as opposed to private organisations due to their more complex decision making processes and diffuse stakeholders groups (O’Riordan, 2016). This is particularly true in healthcare, where the risks associated with quality and safety failures can literally be a matter of life and death (Herzliner, 2016). Figures available on the website for the Irish State Claims Agency outline that at the end of 2014, there were 7,221 claims under management; 2,800 Clinical Claims (39%) and 4,377 General Claims (61%); with a total estimated liability cost of 1,469 million. Crucially however, it was estimated that the Clinical Claims would cost 1,160 million (average of €400,000), while the General Claims would cost 309 million (average €70,600) (www.stateclaims.ie). Given the cost of failure in healthcare, both human and financial, it is easy to understand why “digital culture” characteristics, like agility and an appetite for risk, would prove difficult to establish. Katzenbach et al. (2012) present a case study of Aetna Inc, an American managed healthcare company, who successfully reformed their organisational culture to make their organisation more agile and innovative. Critical to their success was a more distributed leadership structure and allowing for more collaborative ways of working, whereby the CEO and his management team engaged with staff to establish what they valued about the organisation. They then built their business strategy around those organisational values and gained the buy-in of the staff who ultimately implemented that strategy.
Similarly, if Ireland’s Digital Health Strategy is to be implemented, it needs to be aligned with the organisational culture of the Irish Health System. This means that HSE Management but also the Department of Health – most importantly the Minister for Health – need to accept responsibility for developing and supporting a “digital culture”. Interestingly, a Research2Guidance report (2015) ranking the best countries in the EU to start an mHealth business, identified that Ireland ranks highly as an environment to develop mHealth Apps, but significantly lower in terms of Market Readiness (see Figure 2). eHealth Ireland have launched eHealth Connect and the Quality Innovation Corridor
(QIC) Digital Programme to promote and support the deployment of digital innovations into the Irish health system. These programmes represent important strategic steps towards developing market readiness for connected health solutions in the Irish healthcare system. As the above research indicates however, the implementation of these programmes will require a system-wide commitment to developing and supporting a “digital culture”; within which there is no place for blame.
Ash, J.S., Berg, M. & Coiera, E. ‘Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System –related Errors’, Journal of the American Medical Informatics Association 2004; 11: 104-112.
Cullen, P. ‘Why is it hard to punish poor performing HSE managers’, The Irish Times, 11th February 2017; Accessed 17 February 2017: Available at: http://www.irishtimes.com/news/health/why-it-is-hard-to-punish-poor-performing-hse-managers-1.2971512
Dubnick, M.J. ‘Public Service Ethics and the Cultures of Blame’, Fifth International Conference of Ethics in the Public Service: an International Network “Public Sector Ethics – Between Past and Future”, August 5-9, 1996; Brisbane, Australia.
Firth-Cozens, J. ‘Organisational trust: the keystone to patient safety’, BMJ Quality and Safety, 2004; 13: 56-61.
Heitmueller, A., Bull, A.,and Oh, S. ‘Looking in the wrong places: why traditional solutions to the diffusion of innovation will not work’, BMJ Innovations, 2016; 0: 1-7.
Herzlinger, R.E. ‘Why Innovation in Health Care Is So Hard’, Harvard Business Review, Big Picture, 2016; May.
Kane, G.C., Palmer, D., Phillips, A.N., Kiron, D. and Buckley. N. ‘Aligning the Organization for its Digital Future’, MIT Sloan Management Review and Deloitte University Press, July 2016; Accessed 17 February 2017: Available at: file:///C:/Users/Marcella/Downloads/2016_MIT_DeloitteAligningDigitalFuture.pdf
Katzenbach, J.R. Steffen, I. and Kronley, C. ‘Cultural Change that Sticks: Start with What’s Already Working’, Harvard Business Review, July-August 2012: 110-117.
Mudiwa, L. ‘Waiting lists passes 600,000 mark’, Irish Medical Times, 9th February 2017; Accessed 17 February 2017: Available at: http://www.imt.ie/news/waiting-lists-passes-600000-mark-09-02-2017/
O’Riordan, J. ‘Organisational Culture and the Public Service’, Institute of Public Administration, State of the Public service Series, November 2015: Research Paper No. 16; Accessed 17 February 2017: Available at: https://www.ipa.ie/pdf/Organisational_Culture.pdf.
Research2Guidance and mHealth Summit (2015) EU Countries mHealth App Market Ranking 2015: Which EU Countries are best for doing mHealth business, Available for download: research2guidance.com.
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