Governance and Leadership as a tool for Quality enhancement

1. “Governance and Leadership :
A Tool for Quality Enhancement in Health Sciences Institutions”
4 June 2022
Dr. Smriti Arora
Prof. cum Principal, AIIMS Rishikesh

2. Objectives
• What is governance ?
• What is leadership ?
• What is quality enhancement ?
• How Governance and Leadership can be used as a tool for QE ?

3. What is Governance ?
• Governance encompasses the system by which an organization
is controlled and operates, and the mechanisms by which it,
and its people, are held to account.
• Elements of governance
• Ethics
• risk management- prevention from lawsuits
• compliance
• administration

4. • Governance enables the management team and the board to run
organizations legally, ethically, sustainably, and successfully, for
the benefit of stakeholders, including shareholders, staff, clients
and customers, and for the good of wider society.
• governance refers to making, changing, monitoring and enforcing
the rules that govern the demand and supply of health services
Governance

5. Areas of governance activity
• clear decision-making processes,
• behave openly by reporting on their activities,
• actively engage with their stakeholders,
• effectively manage the risks they face (Covid 19 and its sequelae)
• and take responsibility for controlling and protecting their assets,
including their reputation.

6. Governance in healthcare
• It is a structure that holds boards and leaders accountable for continuously
improving operations, clinical staff and processes, society and financial
performance.
• Clinical governance - includes caring for patients, managing clinical
practices and administration, maintaining and improving the quality and
safety of patient care
• Corporate governance - encompasses many matters that aren’t players at all
in clinical governance. Matters such as accounting, finance, investment,
human resources, IT facilities and security all fall under corporate
governance.

7. Stakeholders
• Three main categories of stakeholders who interact with each other
determine the health system and its governance:
1. State- government organizations and agencies at central and sub-
national level
2. Health service providers- different public and private for and not for
profit clinical, para-medical and non-clinical health services
providers; unions and other professional associations; networks of
care or of services
3. Citizen - population representatives, patients’ associations, NGOs,
citizens associations protecting the poor, etc.) who become service
users when they interact with health service providers.

8. Leadership and governance
• ensures strategic policy frameworks exist and are combined with effective
oversight, coalition-building, regulation, attention to system-design and
accountability.
• health leadership plays a crucial role in redirecting the workforce, increasing job
satisfaction, professional development, and burnout prevention
• Leaders are constantly challenged to meet shifting expectations and set new
priorities.
• Health leadership is the ability to recognize priorities, offer strategic guidance,
and create commitments to achieve those priorities.
• Successful leadership encompasses knowledge, skills, and the ability to engage
with a different workforce.

9. Leadership
• Leaders provide a unity of purpose, while also establishing the
direction of the organization.
• Leaders create and maintain the internal environment where
employees are able to become completely involved in achieving
the organisation’s goals and aims.

12. • Research shows that effective leadership is a crucial factor when
there is an ongoing change in an organization and leaders’ job is to
create an inspiring vision that can motivate employees work towards
a common goal.

13. Quality Enhancement
• quality enhancement ‘is a process of augmentation or
improvement’.
• Improvement is often used to refer to a process of bringing
an activity up to standard whereas
• enhancement is about raising to a higher degree,
intensifying or magnifying it.

15. Quality enhancement
Why is QE necessary ?
• When a health care institution aspires towards excellence and patient
safety, quality enhancement proves to be a key factor essential to the
process
• Top management commitment is important as
• Allocate budget and resources
• Monitor progress
• Planning for change

17. Why quality is linked to governance issues ?
• Taxpayers money
• Accountability is an increasingly important element in
the governance of healthcare institutions
• To protect consumers

18. Tips to Improve Quality Management
Leadership and Management
1. Be proactive and lead through example rather than dictating
2. Understand and react to fluctuations in the external
environment
3. Consider the wants of ALL stake holders, from customers to
owners, employees, suppliers, local communities and the
general public
4. Establish common values and ethical role models throughout
the organization – leaders instill a sense of values and ethics
that are entrenched in the organisation’s mission statement,
acting as role models to inspire employees

19. 5. Establish a clear view of the organisation’s prospects – a clear
view of the organisation’s future is essential in order to
accurately plan ahead, by continuously changing goals and
milestones in the future.
6. Develop trust and eradicate fear
7. Equip employees with the needed resources and freedom to
strive for duty and accountability
8. Foster open and honest communication
9. Teach, train and coach employees

20. Advantages of QE process:
✓Safe care – avoiding injuries to patients caused by treatments intended to help them.
✓Timely care – reducing wait times and harmful delays for patients.
✓Effective care – making patients better.
✓Efficient care – avoiding waste, in particular waste of equipment, supplies, ideas, energy,
and resources in general.
✓Equitable care – providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location and socioeconomic status.
✓Patient-centered care – providing care that is respectful of and responsive to individual
patient needs, while ensuring that patient values guide all clinical decisions.

21. Aspects of good health governance
1. Evidence-based policy making. It involves the systematic collection
of high-quality data and analysis of those data with rigorous research
methods, which creates evidence on which decisions can be based.
eg N 95 mask
2. Efficient and effective service provision arrangements, regulatory
frameworks, and management systems- encouraging vaccination
3. Responsiveness to public health needs and the preferences of
beneficiaries’/citizens’ – while also managing their differences
4. Transparency in policymaking, the way resources are allocated, and
performance

22. Aspects of good health governance
5. Responsible leadership to address public health priorities- man ki
baat
6. The legitimate exercise of beneficiaries’/citizens’ voice
7. Institutional checks and balances
8. Clear and enforceable accountability

24. • Good governance is considered a core component of resilient health systems.
• Health system resilience can be defined as the capacity of health actors, institutions,
and populations to prepare for and effectively respond to crises; maintain core
functions when a crisis hits; and, informed by lessons learned during the crisis,
reorganise if conditions require it.
• Health systems are resilient if they protect human life and produce good health
outcomes for all during a crisis and in its aftermath.
• Good leadership is the key to building high-quality healthcare.
Goals :
• improved health status
• reduced financial risk to users of the health system.

25. By focusing on governance and leadership, improved governance and leadership can contribute to an array of downstream
effects, including:

26. Governance and Leadership- steps
• Step 1: Strengthen primary health care policies and leadership
• Step 2: Strengthen quality management infrastructure
• Step 3: Ensure social accountability mechanisms are integrated
throughout the system

27. Governance and Leadership- steps
• Step 1: Strengthen primary health care policies and leadership
National stakeholders must work together to define the scope and
mechanisms of quality PHC policies in their context, and then to
develop and implement those policies.

28. Step 2: Strengthen quality management
infrastructure
In order to ensure access to quality, person-centered health systems,
national health policies, strategies, and plans must be accompanied by
a strong, transparent quality management infrastructure that
integrates standardized care plans, diagnostic protocols, training
programs, and accreditation systems.

30. • Quality management includes three interlinked concepts,
necessary to enhance quality across the health system:
• Quality planning - includes aims, processes, and goals needed to
create an environment for continuous improvement.
• Quality control - entails monitoring established processes to
ensure their functionality.
• Quality improvement - is the action of every person working to
implement iterative, measurable changes, to make health
services more effective, safe, and people-centered.

31. Quality Management Infrastructure
Goals and outcomes
• Establishes infrastructure that supports a health system to deliver
safe, effective, and efficient care
• Enhances quality across the health system while minimizing harm and
resource waste
• Creates an environment for continuous improvement

33. Quality Improvement
 Step 1: Identifying a problem, forming a team and writing an
aim statement
 Step 2: Analyzing the problem and measuring quality of care
 Step 3: Developing and testing changes
 Step 4: Sustaining improvement

34. Step 1
• Identifying problem-
• Data-based: Review local health facility data and
identify gaps related to quality of care
• Value for patient outcomes
• Forming a team
Look for volunteers who are:
 Enthusiastic - they want to make changes
 Involved - they are the ones doing the work that needs
change
 Influential - others people listen to them and they can get
things done

35. Team
➢Need people from every level: from administrators to
cleaners
➢ From all involved departments
➢ Assign some key roles
➢ Leader
➢ Recorder
➢ Communicator

36. Step 2- Analyzing the problem and measuring
quality of care
Tools for analysis
Understanding the current system:
1. Fishbone
2. Five Why’s
3. Pareto Principle
4. Process Flowchart

37. 1. Fishbone : Identify all possible contributing factors
People
Place
Policy
Procedure
Major influence
Major influence
Minor influence
Minor influence
Problem

38. 2. “Five whys”
Understanding why something is the way it is:
 Mothers are not breastfeeding – Why?
 They feel uncomfortable taking their gown off – Why?
 The gown opens at back, so they have to take entire gown off
to breastfeed, so they feel uncomfortable.
 Why they have this type of a gown?
 That is what store keeper orders.
 Why doesn’t the store keeper order gowns appropriate for breast
feeding?
 Because no one has requested him to do that

39. 3. Pareto Principle
80% of the problem is due to 20% of the causes

40. Pareto Chart Example: Medication Error
v
45
20
15
6 5 3 3 2 1
0
20
40
60
80
100
Prescription
Error
Improper
Storage
Dilution
Error
Wrong
Label
Missed
Dose
Wrong
Dose
Expired
Drug
Wrong
Patient
Wrong
Route
80% of the problem is
due to 30% of causes
80% of the problem is
due to 30% of causes
80% of the problem is
due to 30% of causes

41. Steps
Option
(diamond)
Yes
No
Step not clear
(cloud)
Start
(oval)
Steps of the
process
(rectangles)
Steps
Steps
End
(oval)
Steps
Process Flow Chart

42. Process and outcome indicators?
 You measure
process
To learn whether the action
you want done is really
happening or not
 You measure
outcome
To learn whether the
action is really leading to
the desired patient
outcome or not

43. Time-series chart:
Percentage of women receiving uterotonic within one minute
0%
20%
40%
60%
80%
100%
%
of
women
receiving
oxytocin
in
1
minute

44. Step 3
Testing Changes
What is a PDSA cycle?
- Is the change feasible?
- Did the change lead to improvement ?
PLAN
Plan the
change
DO
Test the
change
STUDY
What did you
learn?
ACT
Next steps on
the basis of the
test
Adopt,
Adapt,
Abandon

45. 3. Ensure social accountability mechanisms are
integrated throughout the system
• It includes opportunities for community members to identify and
seek solutions to problems observed in their local health systems.
• Processes for both surfacing and responding to these concerns should
be designed from the outset and integrated as much as possible into
PHC policies from the local to the national level.
• is a measure of whether a country is held accountable to existing and
emerging social concerns and priorities based on need
• It includes a set of approaches and tools to promote citizen
engagement and monitoring to improve system performance,
effectiveness, and responsiveness to public needs.

47. • Democratic accountability includes systems, laws, and contexts that
build an enabling environment for citizen-led accountability. It
includes :
• Transparency- release or publication of the data and information
needed for citizens to monitor the health system.
• Responsiveness- it include government actions to respond to
needs or requests that arise during citizen monitoring.

48. • Performance accountability is defined as initiatives
and actions by citizens and civil society organizations
to hold government and service providers
accountable for their performance through bottom-
up monitoring and engagement.
• Social accountability works best with coordinated
efforts from two key sets of actors: those with
decision-making power, and citizens or civil society.

49. How governance can be used as tool to
enhance QE ?
• Engaging the population, civil society and communities
into policy and decision making. National health policies,
strategies and plans are more likely to be implemented
effectively if their development and negotiation is inclusive of all
relevant stakeholders.
• Strengthening legal framework- The creation of a formal legal
mandate creates a drive for action and a commitment to work
on policies and programs eg wearing masks in public
• Transparency

50. Leadership
• PM’s ability to get citizens to exercise self-discipline, especially
in the early days of the pandemic, through initiatives such as
lighting lamps to applaud corona warriors, or banging utensils to
express solidarity, or appealing to citizens consistently to wear
masks. It enabled people’s participation, which made it easier for
the government to pursue the battle.

51. Summary
• Through good governance and leadership, we have crossed an important
phase in the battle against the pandemic.
• In India, along with the central and state governments, 1.3 billion citizens
fought against the pandemic
• Successful outcomes improvement in healthcare requires strong leadership to
make decisions, allocate resources, and prioritize initiatives.
• Effective governance in healthcare includes
• Engage the right stakeholders.
• Establish a shared understanding of objectives.
• Practice disciplined prioritization.

52. BENCHMARKS OF EFFECTIVE GOVERNANCE
• Board members- clear mission, vision and core values
• Competent and dedicated board members and workforce
• Participative Decision making
• Transparency
• Accountability
• Continuous monitoring and evaluation
• Key priority- quality
• Coaching and training

53. References
• https://improvingphc.org/improvement-strategies/governance-
leadership
• https://www.qualityze.com/5-key-components-of-quality-
improvement-in-healthcare/

54. THANK YOU