Large scale organisational intervention to improve patient safety in four UK hospitals:mixed method evaluation

Objectives: To conduct an independent evaluation of the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design: Mixed method evaluation involving five substudies, before and after design. Setting: NHS hospitals in United Kingdom. Participants: Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention: The SPI1 was a compound (multicomponent) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results: Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration - monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items) - there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for "difference in difference" 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from17%(63) to13%(49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.

Managing enterprise resource planning and multi-organisational enterprise governance:a new contingency framework for the enterprisation of operations

This research has been undertaken to determine how successful multi-organisational enterprise strategy is reliant on the correct type of Enterprise Resource Planning (ERP) information systems being used. However there appears to be a dearth of research as regards strategic alignment between ERP systems development and multi-organisational enterprise governance as guidelines and frameworks to assist practitioners in making decision for multi-organisational collaboration supported by different types of ERP systems are still missing from theoretical and empirical perspectives. This calls for this research which investigates ERP systems development and emerging practices in the management of multi-organisational enterprises (i.e. parts of companies working with parts of other companies to deliver complex product-service systems) and identify how different ERP systems fit into different multi-organisational enterprise structures, in order to achieve sustainable competitive success. An empirical inductive study was conducted using the Grounded Theory-based methodological approach based on successful manufacturing and service companies in the UK and China. This involved an initial pre-study literature review, data collection via 48 semi-structured interviews with 8 companies delivering complex products and services across organisational boundaries whilst adopting ERP systems to support their collaborative business strategies – 4 cases cover printing, semiconductor manufacturing, and parcel distribution industries in the UK and 4 cases cover crane manufacturing, concrete production, and banking industries in China in order to form a set of 29 tentative propositions that have been validated via a questionnaire receiving 116 responses from 16 companies. The research has resulted in the consolidation of the validated propositions into a novel concept referred to as the ‘Dynamic Enterprise Reference Grid for ERP’ (DERG-ERP) which draws from multiple theoretical perspectives. The core of the DERG-ERP concept is a contingency management framework which indicates that different multi-organisational enterprise paradigms and the supporting ERP information systems are not the result of different strategies, but are best considered part of a strategic continuum with the same overall business purpose of multi-organisational cooperation. At different times and circumstances in a partnership lifecycle firms may prefer particular multi-organisational enterprise structures and the use of different types of ERP systems to satisfy business requirements. Thus the DERG-ERP concept helps decision makers in selecting, managing and co-developing the most appropriate multi-organistional enterprise strategy and its corresponding ERP systems by drawing on core competence, expected competitiveness, and information systems strategic capabilities as the main contingency factors. Specifically, this research suggests that traditional ERP(I) systems are associated with Vertically Integrated Enterprise (VIE); whilst ERPIIsystems can be correlated to Extended Enterprise (EE) requirements and ERPIII systems can best support the operations of Virtual Enterprise (VE). The contribution of this thesis is threefold. Firstly, this work contributes to a gap in the extant literature about the best fit between ERP system types and multi-organisational enterprise structure types; and proposes a new contingency framework – the DERG-ERP, which can be used to explain how and why enterprise managers need to change and adapt their ERP information systems in response to changing business and operational requirements. Secondly, with respect to a priori theoretical models, the new DERG-ERP has furthered multi-organisational enterprise management thinking by incorporating information system strategy, rather than purely focusing on strategy, structural, and operational aspects of enterprise design and management. Simultaneously, the DERG-ERP makes theoretical contributions to the current IS Strategy Formulation Model which does not explicitly address multi-organisational enterprise governance. Thirdly, this research clarifies and emphasises the new concept and ideas of future ERP systems (referred to as ERPIII) that are inadequately covered in the extant literature. The novel DERG-ERP concept and its elements have also been applied to 8 empirical cases to serve as a practical guide for ERP vendors, information systems management, and operations managers hoping to grow and sustain their competitive advantage with respect to effective enterprise strategy, enterprise structures, and ERP systems use; referred to in this thesis as the “enterprisation of operations”.

The role of wisdom in organisational leadership

This thesis begins with a review of the literature on wisdom models, theories of wise leadership, and existing wisdom measures. It continues with a review of how the concept of wisdom may add value to existing leadership models, highlighting the need to empirically identify the characteristics of wise leaders and develop a wise leadership measure. A nomological framework for wise leadership is then presented. Based on a review of the wisdom and leadership paradigms, a mixed-methods research design is described for three studies to define the characteristics of wise leadership in organisations; identify specific leadership challenges that might require wise responses; and to develop the wise leadership measure comprising of vignettes. The first study involves critical incident interviews with 26 nominated wise leaders and 23 of their nominators, which led to the identification of nine wise leadership dimensions which include Strong Ethical Code, Strong Judgement, Optimising Positive Outcomes, Managing Uncertainty, Strong Legacy, Leading with Purpose, Humanity, Humility, and Self-Awareness. The second study includes critical incident interviews with 20 leaders about organisational challenges associated with the nine dimensions, to elucidate the wise leadership measure. The third study includes the design of 45 vignettes based on organisational challenges that measure the nine wise leadership dimensions. The measure is then administered to 250 organisational leaders to establish its construct validity, leading to the selection of 18 vignettes forming the final wise leadership measure. Theoretical, methodological and practical implications of this research are then discussed with recommendations for future research.

Leadership and organisational outcomes in healthcare

This research examined to what extent and how leadership is related to organisational outcomes in healthcare. Based on the Job Demands-Resource model, a set of hypotheses was developed, which predicted that the effect of leadership on healthcare outcomes would be mediated by job design, employee engagement, work pressure, opportunity for involvement, and work-life balance. The research focused on the National Health Service (NHS) in England, and examined the relationships between senior leadership, first line supervisory leadership and outcomes. Three years of data (2008 – 2010) were gathered from four data sources: the NHS National Staff Survey, the NHS Inpatient Survey, the NHS Electronic Record, and the NHS Information Centre. The data were drawn from 390 healthcare organisations and over 285,000 staff annually for each of the three years. Parallel mediation regressions modelled both cross sectional and longitudinal designs. The findings revealed strong relationships between senior leadership and supervisor support respectively and job design, engagement, opportunity for involvement, and work-life balance, while senior leadership was also associated with work pressure. Except for job design, there were significant relationships between the mediating variables and the outcomes of patient satisfaction, employee job satisfaction, absenteeism, and turnover. Relative importance analysis showed that senior leadership accounted for significantly more variance in relationships with outcomes than supervisor support in the majority of models tested. Results are discussed in relation to theoretical and practical contributions. They suggest that leadership plays a significant role in organisational outcomes in healthcare and that previous research may have underestimated how influential senior leaders may be in relation to these outcomes. Moreover, the research suggests that leaders in healthcare may influence outcomes by the way they manage the work pressure, engagement, opportunity for involvement and work-life balance of those they lead.