Etapa VII: Implementación y control del plan estratégico

The key finding here is that, as might be expected, change required not only a change in organisational structures and procedures, but also a change in the attitudes and values of the workforce. All three sites had structures and

processes in place to implement change and to try to control hospital activities, for example each site had governance processes to implement clinical guidelines. Nevertheless, the organisational norms and level of compliance with these

case when the hospitals were implementing new or updated NICE guidance. The administrators who were responsible for these processes at all three of the sites reported problems with clinical engagement and compliance with the processes. The quote below reveals the multiple issues at play and the variation that was commonplace. When asked if the identified clinical leads responded to the requests about NICE guidance implementation, the administrator at Site A said:

“Some we do, but then some we don’t get any back, and then we have a procedure then to follow up non-compliance, or non-response to our emails. But it’s then that, if they say, “Yes, we’ve met it”, it’s the evidence to show that they are actually meeting it. Yes, a lot of it, you know, it is down to, you know, just taking the word that, you know, that a consultant’s going to come back and say, “Yes, we’re compliant to this”, [it’s] not good enough.” (INT A 218015)

It was interesting that an email from the consultant was “notgood enough” to

demonstrate that compliance to the process had been achieved in site A. This was not the case in site C, as described by the administrator responsible for NICE guidelines in that Trust:

“We do have a process. We ask them to complete that form initially to say…I mean, we hope that they’ll say at least that, that they intend to become fully compliant. I think not all the quality standards get implemented within two years but they seem to be working towards it so that’s acceptable. But however, if they tick six or seven, an exception report is required, which is that one there, so basically they’ve just got to say…Why, yes, in a word… The people who are best at filling out these are nurses, midwives, rather than consultants. I think they take more time. The medical staff are not good at doing it. They just don’t have the protected time. And again that’s

understandable.” (INT A 198002)

This finding is supported by my reflections which describes “tick box compliance”

to NICE guidance that seemed to be the norm at site C:

“Despite this reported process, I asked to look at the report for the particular hip replacement guidance I was interested in (TA304). The administrator looked it up on the database as it was highlighted green and she told me it was compliant. Out of interest I asked to see what evidence the department had provided to show their compliance. It turned out that the lead surgeon in this hospital has written “we are compliant J (signed first name)”. I asked if this was sufficient evidence and the administrator said yes, they have to take the clinician’s word for it. I thought this was a

classic case of tick box compliance and was not really evidence of anything other than getting a response to a question.” (OBS notes Site C notes from INT A 198002)

Lastly, the situation at site B appeared to mirror that found in site C. This

administrator asks the consultants “is it relevant?” “do you think we are

compliant?” and accepts a ‘yes’ or ‘no’ response as sufficient:

“So you know at the very least they’re going to... you know.They’re going to read that. So anyway, and then we ask them... So they normally give... The director will give it to the person that is most specialist, I guess, you know, in their area, and then it’ll say, ‘Is it relevant? Do you think that we are compliant? If not, why do you not think that we’re compliant? Please state. Can you evidence that we are compliant? Can you tell us of some pieces of work to evidence that we are compliant with this? Do you see there being any training needs?’ It’s that kind of stuff. But it’s a ‘Yes/No’ with a comment rather than asking them to produce a statement, you know, and that’s one of the things that we found didn’t work, you’d just sit there waiting for things to come back and it just doesn’t happen.”(INT A 119009)

Elsewhere this administrator used the words “professional responsibility” and

“duty”. This expectation of action and obligation of the clinicians with regards to

NICE guidance was not evident in the interviews with clinical staff. Instead, one senior surgeon who sat on the surgical board in the Trust referred to NICE

guidance as “another layer of administration”(INT C 37003).

Together, these findings demonstrate two distinct sets of beliefs, attitudes and considerations of knowledge between the organisational sub-cultures in this site. They were working at polar opposite points of view, both appearing to believe that NICE guidance was the responsibility of another sub-group.

The narratives above demonstrate the lack of an evidence-based feedback loop between administrators, managers and clinicians. This seemed to be accepted within the culture of the organisations. However, site A commented that they were making changes to their policy to try to establish more effective knowledge mobilisation processes. Organisational culture appears to be an important factor in understanding the ability of a hospital to achieve performance targets in line with the organisational strategy.