Successful Operational Management - Essay Example

Running head: OPERATIONAL MANAGEMENT Operational Management [Name Of Student] [Name Of Institution] INTRODUCTION The immediate background to the development of models of community care for people with health &fitness problems and other form of severe illness is well known. In the 1950s there were more than 150,000 beds in long-stay psychiatric hospitals, the majority of which were occupied by people with a diagnosis of fitness troubles. Today there are less than 30,000. Since there is no reason to suppose that fitness troubles is any less prevalent now than it was 40 years ago, we must ask what has happened to those people who would previously have been looked after in hospitals? Where are they now and what kind of care are they receiving? AIM OF THE PAPER In this paper I shall discuss the statement that ’Successful operational management is based upon the application of sound systems of work’ with reference to the healthcare sector. DISCUSSION The Griffiths Report, which was accepted and implemented by the government in 1983, was highly critical of the NHS management at all levels. It identified the failure of management as the central problem of the NHS (Mitchell & Vousden, 1985). In this respect, it criticized 'consensus management', mentioning the lack of a clearly defined general management function throughout the NHS. By general management, it meant the responsibility drawn together in one person, at different levels of the organizations, for planning, implementing and control of performance. The report also found a lack of identifiable individuals who would accept personal responsibility for real continuous assessment of performance against such measures as level of service, quality, budget control, cost improvement, productivity, and motivating and rewarding staff (Bowman, 1986, p. 40). The report recommended the establishment of general management at the various levels in the NHS. General management implied a single individual who would deal with strategic management. The general managers were expected to stimulate initiative, urgency and vitality, and to bring about a constant change for improvement and cost reduction, and to secure proper motivation of staff (Bowman, 1986, p. 41). They were also responsible for policy execution, service efficiency and effectiveness, the improvement of health service performance and, not least, a greater awareness of customer needs and preferences (Barnard & Harrison, 1986, p. 1216). The development of effective models of community care in the UK has been slow and patchy and the current preoccupation with shortages of beds and `overoccupancy' in acute admission wards can be directly related to the failure to develop community alternatives such as supervised housing, work and employment schemes, intensive community support teams, etc. Without such services, it is entirely predictable that those who have the most severe and disabling conditions will accumulate in hospital, or will rotate ever more rapidly in the `revolving door' of acute admission, premature discharge to inadequate support in the community, relapse and re-admission. Such is the fate of many people with severe fitness troubles nationally. Given the relatively small room for manoeuvre in health budgets (because of the high contribution of inpatient costs) Health Authorities and Trust managers have thus been caught between the proverbial `rock and a hard place' and there has been little incentive to develop specialist services for people with fitness troubles. Perhaps the new White Paper (Department of Health, 2004b) will help redefine this relationship between primary care and specialist health services and assure more equitable (and effective) forms of `targeting': we will have to wait and see. A culture of `blame' has also grown up which is fundamentally antithetical to the development of new services. This has been fuelled by well-publicised cases of `untoward incidents' in which members of the public have suffered death or injury apparently at the hands of people with serious health problems (mostly schizophrenia). The public inquiries, which have inevitably followed under the terms of the Guidance note HSG(94)27 (Department of Health, 2003b) have led to a widespread loss of confidence that anything can be done to salvage' community care' and that, from a policy point of view, it has demonstrably failed. Many professionals now seem to share this bleak conclusion. These are not exactly the most promising conditions for the development of innovative community services. LITERATURE REVIEW What constitutes quality is a difficult question for health care providers because quality has many dimensions. A brief review of the health care literature shows the problematic nature of the definition of quality. For instance, Dopson and Cabbay (1987) indicated that quality spans four broad areas: consumerism, professional and technical standards, establishing a suitable balance of service, and ensuring value for money. These dimensions of quality are partly derived from the work of Maxwell (1984) and Shaw (1986a, b) who see these as integral aspects of quality. Others see quality as the appropriateness and effectiveness of the clinical care delivered to patients, and the manner in which this care is delivered (NHS Management Bulletin, 1986, p. 2). Seen from this perspective, efficient technical care delivered without compassion, courtesy or regard for the patient's wishes is unlikely to satisfy most people's criteria for quality. Robinson and Strong (1987,p. 11), building on Vuori's (1982) and Maxwell's (1984) views on quality, add the concept of humanity. Humanity here implies the provision and delivery of health care which is sensitive to the complexity of individual needs, including human dignity. Sloan (2002,p. 65) provides a discussion of the difficulty in defining health care quality, mentioning that consumers tend to emphasize responsiveness, symptom relief and courtesy, funders are concerned about efficiency, while providers value technical skills and desired outcome. Searstone (2001) argues that due to the lack of agreement on the definition of quality, some writers on the topic prefer to use such measures as 'fitness for purpose', 'conformance to specification' or 'satisfying customer needs'. Searstone (2001,p. 249) cites some internationally agreed definition of quality as: The totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs. The adaptation of this definition of quality to health care has two different sides, either stated or implied, which affect quality management in an organization: that is, the what and how. The 'what' deals with the quality and efficiency of treatment and the 'how' the administration of care, contact with nurses, premises, hygiene and so on. According to Giles and Williams (2001,p. 29) the 'what to do' implies using quality management to satisfy internal and external customers (patients and staff). It also includes regular measurement of customer satisfaction and the implementation of plans for improvement and monitoring. This implies cross-functional cooperation to deliver what the customer wants. On the how-to-do-it, managers motivating and empowering all employees in the organization achieve quality management. Thus, senior management sets priorities and initial goals and allocates responsibility. Resource needs and senior management supports required are determined. Senior management provides the agreed resources (people, money, training, machines, etc). Measurable goals are set to ensure that everyone's work and priorities, which have been clearly defined, fit in with the organization's priorities. Again, progress is thus monitored regularly according to an agreed timetable, extra resources are allocated if necessary, and attainments are swiftly rewarded (Giles & Williams, 2001, p. 29). From the above discussion, it follows that a quality management programme involves two different elements, namely QA and TQM. What, then, is meant by QA in health care? As Kogure (2002) explains, the definition of QA differs slightly from country to country but the content is almost the same. Citing some internationally agreed definition, both Kogure (2002,p. 9) and Searstone (2001,p. 250) define QA as: All those planned and systematic actions necessary to provide adequate confidence that a product or service will satisfy given requirement for quality. Kogure mentions that another definition adds the words 'by the producer' to clarify whose activity it is. It follows from the definition above that quality can only be achieved if it is planned and systematic. This implies anticipation of potential problems and then avoidance, i.e. defect prevention (Searstone, 2001, p. 250). Thus, QA is prevention to reduce or eliminate deficiencies. As part of QA, there is the need to have quality control, which is defined by Searstone (2001,p. 250) as: "The operational techniques and activities that are used to fulfil requirements for quality". This definition implies the techniques and activities undertaken to monitor services and provide feedback for corrective action. Kogure goes on to give three functions of QA. He argues that QA should contain some customer-oriented activities as well as ordinary quality control activities. The deliverer of the service should carry out activities to ensure quality and take responsibility for assuring quality to meet customers' requirements while at the same time carrying out discrete, customer-oriented activities to provide circumstances where customers can obtain services with confidence. According to this perspective, QA provides three fundamental functions, namely securing quality, ascertaining quality and verifying quality. The first involves an in-built quality process, the second involves such issues as inspection, quality audits and survey of customer satisfaction, and the third involves activities which tell customers about securing and ascertaining quality. Examples are the issuing of certificates, systems to prevent recurrences such as projects undertaken by quality circles, and preventions in advance as well as dealing with customers' complaints and compensation. In the health care setting, MacDonald and McCoy (1987) suggest that QA is the method for assuring that a quality product is continuously delivered. Specifically, MacDonald and McCoy (1987,p. 24) define QA as: The process of assuring the consumer a specific degree of excellence of a product or service through continuous measurement and evaluation, using established criteria and standards, for the purpose of improving the product or service . . . In a health care context, it is accomplished by developing and implementing both hospital and departmental standard of practice. Collard and Sivyer suggest that a QA system should be backed by TQM, which they define as: A cost-effective system for integrating the continuous quality improvement efforts of people at all levels in an organization to deliver products and services which ensure customer satisfaction. They admit that this definition, while imperfect, conveys the idea that TQM goes beyond the functions of QA, which emphasizes the prevention of deficiencies. Thus, although TQM is not a technical system, it fosters a sense of quality consciousness, awareness, motivation, understanding and commitment of employees at all levels. In this respect, TQM is a management philosophy which links customer needs to organizational goals. It involves every department, function and process in the organization and the active commitment of all employees to meeting customer needs (Searstone, 2001, p. 251). TQM then is a cultural phenomenon and as such QA is not the same as TQM. QA ensures that controls are in place to ensure excellence in the provision of services (Cheng, 2002) and furthermore to ensure that the service meets customers' needs and expectations of quality. TQM is much more than that. As Giles and Williams (2001,p. 30) put it, TQM is a long-term and holistic approach to people and systems which links quality consciousness and culture into the whole organizational strategy. Often, there is confusion about TQM and QA. There is the tendency to label all other approaches to quality management as TQM. Giles and Williams (2001) and Nesbit (2002) argue that TQM cannot be pursued in isolation as strategy must be aligned to culture. Giles and Williams warn that using QCs, suggestion schemes, and so on as quick-fix formulae for curing organizational illness is a clear recipe for failure in TQM. In discussing some of the common barriers to successful TQM implementation, Nesbit argues that often TQM fails in the sense that (a) no fundamental change occurs in the way the management operates, and (b) ownership of quality still remains under the control of the quality department. THE RANGE OF INTERVENTIONS The range of interventions necessary to support a comprehensive, community service for people with severe and enduring health problems are well described in the `Spectrum of Care' document (Department of Health, 2004a). They comprise the following elements. Accommodation It is something of a truism to state that without adequate accommodation effective community care is impossible, but nevertheless it bears repeating. What is difficult is to specify the precise levels of the different kinds of accommodation that are required. Attempts have been made (e.g. Wing, 2002; Strathdee et at., 2000); however, general prescriptions always require qualification based on local conditions. The greatest shortages are still probably regarding high support housing of various kinds (including `24-hour nursed beds') but even then the possibilities of substitution of one kind of facility or service by another (e.g. intensive support teams instead of high support housing) make `normative planning' difficult. Work and employment Next to accommodation, most users place work and/or employment as their next, most urgent, priority (Rogers et al., 2003; Shepherd et al., 2004). Again, the aim must be to provide a range of work opportunities -- assessment and training, placement in open employment with support, sheltered social firms and co-operative businesses, etc. (see Pozner et al., 2000) to cover the range of users' needs. However, just as is in housing, one should not expect everyone necessarily to move through the system, acquiring progressively more skills and independence and therefore requiring less and less support. Some will and some will not. It is therefore important that individuals are allowed to settle at their own `level'. There must be opportunities to move on (e.g. toward open employment) but also opportunities to stay if this is more consistent with the individual's wishes and abilities. Users also value services that they see as having a positive `image' and as being well regarded by others (Dick & Shepherd, 2004). It is thus insufficient that professionals regard a particular work programme as representing `good practice'. The crucial question is, `Do users want to go?' If not, then it does not matter what the professionals think, it is unlikely to engage some of the most difficult, younger people with fitness troubles who actively reject conventional day and work programmes. Specialist community teams If services are going to work successfully with the most difficult and disabled people, then there need to be specialist teams, clearly targeted, with small, protected caseloads (n=10-15), `extended hours' of operation (i.e. outside Mon./Fri. 9-5) and the capacity to deliver intensive support (i.e. daily visits) using an `assertive outreach' model. Such teams have been developed in the US and Australia (Thompson, Griffith & Leaf, 1990; Hambridge & Rosen, 2003) and are now beginning to appear in this country (Ford et al., 2004) but progress is slow. It is important to distinguish between these `intensive support' teams and `crisis intervention' services. Although the two kinds of teams share some features in common (e.g. assertive outreach, extended hours, intensive visiting) the skills mix and methods of working are quite different. Thus, `crisis teams' tend to be focused on the short-term, with an emphasis on symptom resolution; whereas intensive support teams have a longer-term perspective, with more of an emphasis on support and the optimizations of social functioning. Crisis teams are therefore much more reliant on the use of medication and hospitalization, with the aim of rapid symptom stabilization; while intensive support teams give more emphasis to practical help, social support, and facilitating access to `mainstream' community activities. In-patient beds The final elements in the necessary range of services to support people with serious and enduring illness in the community are in-patient beds. No matter how good the models of intensive support (or crisis intervention) are in the community, from time to time users will continue to require in-patient admission. It was noted earlier that, currently, acute inpatient beds are often in very short supply. H-however, as many as a quarter of such beds may be occupied by people who staff consider to be `inappropriately placed' (Shepherd et al., 2004). The majority of these would be better (and less expensively) looked after in a variety of supported settings in the community if these were available. The problem is that such facilities are generally in very short supply and so are the intensive community teams which would make possible the use of a wider range of ordinary housing options. Hence, we have the impression that community care is `failing'. Ideally, the community and in-patient teams should work together as an integrated system, with the same medical input to both elements. However, studies of the quality of inpatient care reveal generally poor integration between hospital and community services (Beadsmoore, personal communication). Community teams therefore need to develop `assertive in reach' to the in-patient units as well as `assertive outreach' to the community. This interface between community and in-patient services is critical to the successful management of people with long-term, relapsing fitness troubles. The Evidence Accommodation There is a dearth of evidence regarding the effectiveness of different kinds of community accommodation. Nevertheless, it is clear that most long-stay patients resettled from hospital show lower levels of symptoms (particularly `negative' symptoms), have better social! integration, and report higher levels of satisfaction, compared with matched cohorts who remain in hospital (Leff, 2004). Costs are also marginally less than in hospital. Not surprisingly, costs increase with increasing levels of dependency. The higher levels of reported satisfaction among the community cohorts seem to be directly related to the less restrictive environments in community residential settings. This provides a link between quality of care measures and quality of life indices (Shepherd et al., 2000). To improve the quality of life of people with fitness troubles in the community we therefore need to focus on changes which will increase their range of choices and opportunities (e.g. over meals and mealtimes, access to rooms and personal possessions, etc.). Even in some community settings these may be difficult to arrange: in hospital they may be virtually impossible. In terms of user preferences, it is quite clear that most patients prefer more independent living arrangements, combined with flexible staff support, rather than staff `on site' and having to live with a group of other people with severe illness (Tanzman, 2003). These aspirations are understandable, but may cause problems when it comes to the care of the most disturbed (and potentially `risky') individuals. It is clearly desirable to try to offer them placements in ordinary housing, but in practice this may heighten fears for the individual's and others' safety. It may also provoke considerable resistance from the local community if they become aware that such developments are planned. Because of these problems, the concept of `24-hour nursed beds' has been suggested in an attempt to combine high levels of professional supervision with a relatively low degree of `institutionalization' (NHSE, 2000). This idea is very similar to the concept of a `ward-in-a-house' or `hospital hostel' which was proposed some years ago for the most difficult `new' long-stay (Young, 2001). The evidence for the effectiveness of these models has been reviewed in Shepherd (2004) and Shepherd (in press). It seems that they may be effective in improving the functioning of up to 40% of those referred sufficiently for them to be resettled into less highly supervised accommodation in the community after an average 2-3 years. Residents generally make more progress than controls regarding their social functioning; they show increased contact with the community and higher levels of satisfaction. Again this seems to be associated with the increased privacy and choice associated with domestic scale living arrangements and the more `normal' atmosphere. For those who are not resettled, the units are more effective in maintaining their functioning than traditional long-stay wards or acute admission units. Costs are generally less than acute beds, but greater than long-stay wards in mental hospitals. Despite these positive results, such options remain unattractive to many of the patients they are designed to serve. For them, privacy, autonomy and practical help with money, food, laundry, etc., from staff who are very much kept at `arm's length', may be much more important than professional support, medication and considerations of public safety (Rose & Muijen, 2004). There is therefore a problem: on the one hand it is clearly desirable to go along as far as possible with users' expressed preferences, or we risk losing their trust and undermining their engagement with services. On the other hand, we need to ensure that the settings in which people are cared for are both cost effective and safe. This is a. real dilemma. The only way forward would seem to continue with the development of ordinary housing options, but combine this with intensive support from specialized teams (see below). Work and employment The circumstantial evidence in favor of the effectiveness of work and employment in contributing to favorable long-term outcomes for people with serious illness is very strong (Warner, 1985; Shepherd, 2004). However, in the UK context, the specific evidence for particular models of vocational rehabilitation and the comparative evidence regarding outcomes between different approaches -- sheltered social firms and co-operatives, placement and `job coach' models, user led businesses, etc. -- is weak (Grove et al., 2004). These projects tend to be small scale and do not lend themselves easily to conventional random controlled trials. Hence, most of the available evidence consists of uncontrolled, descriptive studies (e.g. Nehring et al., 2003; McCrum et al., 2004). An interesting recent report concerns the employment of service users in various capacities within health services (Perkins et al., 2004). Specialist community teams The outcome evidence from randomized controlled trials of assertive community treatment suggests that it has significant advantages compared with standard follow-up arrangements in terms of engaging and maintaining contact with users, reducing the use of hospitalization, improving satisfaction and producing some positive changes in social functioning (Bums& Santos, 2004). There is some variability in these results. but this is largely due to `fidelity' problems (i.e. failure to adhere to interventions of known effectiveness, see `Methodological problems' below). The advantages in terms of enhanced engagement and maintained contact is particularly important as loss of contact has been a common feature of many of the unfortunate incidents where community care has gone disastrously wrong (e.g. Ritchie et al., 2003). The effects on hospitalization rates are similarly important, both in clinical and in financial terms. They seem to be stronger with regard to reducing the number of days in hospital, rather than number of admissions. Reduced days in hospital then partially explains the very consistent findings of enhanced user satisfaction. This is also reinforced by the improved continuity of care which is a central element of successful intensive community support. The findings with regard to improved social functioning (housing, occupation, social networks, etc.) are more patchy and generally only follow if there is specific targeting of these outcomes (e.g. as in the supported employment models). Changes in social functioning also take longer to appear and probably reflect as much about the adequacy of local social `infrastructure' and the ability of teams to link with this as they do about the effectiveness of the teams per se (Ford et al., 2000). In relation to crisis intervention, Kluiter (2004) has recently reviewed the outcome evidence and concluded that various community alternatives (day treatment, home-based treatment, assertive case management, etc.) produce at least equivalent outcomes to inpatient admission for the majority of those referred. Community based treatment generally shows no difference with regard to symptomatic outcomes (providing there is adequate access to accurate diagnosis and effective medication regimes), social recovery is usually quicker, and -- as with longer-term intensive support -- user and career satisfaction is enhanced. Not surprisingly costs are less if there are significant reductions in in-patient days (Knapp et al., 2003). In-patient care Most people would agree that access to acute in-patient beds is a necessary prerequisite of an effective community-based service for people with psychotic disorders. However, the evidence in favor of the effectiveness of acute in-patient care is surprisingly sparse. (This is perhaps doubly surprising given the fact that acute in-patient care generally accounts for about three-quarters of the total budget for health services.) As indicated, acute care has often been used as the `control condition' against which various community alternatives have been compared and has seldom been found to be superior. CONCLUSION This brings us to the final area: that of reducing stigma and presenting more positive role models. The direct involvement of users in service provision may be one route into this, but for many people with severe and enduring health problems living in the community `stigma' is a palpable reality, a recurrent feature of their everyday lives (Rose, 2004). 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