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AUSTRALIAN MEDICAL ASSOCIATION (WA)
The crisis of staff morale and culture at Princess Margaret Hospital has brought into sharp focus just how bad it can get when hospital executives fail to engage their doctors, nurses and other staff. Everyone recognises that executives are under enormous
pressure in trying to run large institutions and provide more care with less money. It gets even worse when you have to plan the move to a new hospital with no timetable for the actual opening.
However, hospitals are built around the staff that run them and like any business, hospitals can only provide high quality care to patients if the staff are on board. Thankfully, the PMH review group did not find any evidence of impact on patients, but experience from other countries would suggest that the quality and safety of care at the hospital is likely to have suffered. This could have manifested in errors, delays to care, increased costs of care and maybe even direct patient harm.
Although PMH is the hospital in the most trouble, it is very clear that all of our public hospitals have similar problems. Since the report was published, the AMA has been contacted by doctors across the State with stories much the same as what was happening at PMH. Common themes include poor engagement with staff and doctors in particular, executives who treat staff with a lack of respect, changes implemented without consultation, lack of clear direction, staffing problems leading to lack of access to leave and fear of retribution if a clinician speaks out.
All doctors work on short-term contracts and this has contributed to the very real possibility that a doctor who speaks out may not have their contract renewed. Management structures have resulted in clinicians becoming further isolated from decision making and many doctors remain cynical about the structures within which they work. Clinical departments are rarely able to manage their own budgets and even the most basic decisions have to be sent up a management chain rather than being dealt with at the coalface. Much has been written about medical engagement and how to set up hospitals to achieve their aims. It has been demonstrated that better medical engagement is associated with safer, higher quality and more efficient care.
The goals are really quite simple and make a lot of sense, but for some reason our public hospital bureaucracy has been unable to deliver on many of these. High performing hospitals have strong, stable leadership, devolved governance and decision making, minimal executive, a strong leadership culture and a clear set of values. Our hospitals fail on most of these measures and it is time for change. Studies have suggested that hospitals that have achieved good medical engagement have developed a positive strategy to engage doctors and worked hard at it. It is not enough to say that doctors are respected and valued – it must be embedded in the culture of the institution.
So what is my prescription for change?
• Trust your clinicians
• Develop leaders
• Equip them to succeed
• Ask them what help or training they need in order to get the job done
• Give them agreed budgets and targets to work to and help them achieve those targets
• Get rid of bloated middle management and ludicrous decision-making processes
• Demonstrate the institution’s values in day-to-day decision making and in all interactions with staff
• Embed respect into the culture.
All of our hospitals would claim to foster a culture of respect, but turning that into reality is difficult and has not been achieved in most of our public institutions. If a Head of Department has no delegated authority to do anything, it is easy to see how they would feel
disempowered, and for that feeling to spread out across the medical staff within the departments. Clinicians do not automatically make good leaders or good managers, but there are plenty of great doctors in our health system who would put themselves forward for leadership positions
if they felt supported, trained, valued and if they perceived they had any chance of success. Another problem we have with culture is around what we value in healthcare. The focus is on a range of arbitrary ‘quality’ measures and in particular on the cost of delivering health services. We also need to start measuring and reporting on the right outcomes – factors such as patient satisfaction, patient clinical outcomes, staff satisfaction and engagement, research and teaching outputs are critical and will not be achieved if all we do is look at the cost of care.
In fact, cost is likely to be reduced if we get those things right. Hospitals and departments should be accountable for the quality of their patients’ outcomes and given the tools to help them meet their targets. With greater delegation, autonomy and trust we are likely to see better financial and clinical outcomes.
It is critical that the Health Service Boards, Health Department and Minister for Health respond to this deteriorating situation quickly and effectively. Change will take time, but it needs to start now and the AMA will do all in its power to ensure that it does.