GHS5850 Nursing Leadership and Management : Public and Private Sectors

Part One
A policy is a statement of intent, or a course or principle of action. Australia’s national health care policy is overseen by the Australian Government, with key elements (such as the operation of hospitals) operated by state governments (DHHS, 2016). In essence, the Australian Government has primary responsibility for community and public health. In Victoria, this is overseen by the Department of Health and Human Services. Their motto is to “aspire for all Victorians to be healthy, safe and able to lead a life they value”. They “deliver policies, programs and services that enhance the health and wellbeing of all Victorians” (DHHS, 2016).  
In March 2015, a cluster of perinatal deaths that had occurred during 2013 and 2014 at Djerriwarrh Health Services was brought to the attention of the Department of Health and Human Services (the department) by the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM). After it was found that seven of these deaths were potentially avoidable, an independent review was conducted by the Australian Commission on Safety and Quality in Health Care (ACSQHC) into the department’s actions in relation to these deaths and to examine the department’s capacity to detect and respond to emerging critical issues in the public health system. Post evaluation, the ACSQHC, identified significant issues and found that in respect to Djerriwarrh, significant deficiencies in clinical governance were not detected, and worse, that the departments processes were not capable of detecting these deficiencies.  In light of these findings, the Minister for Health requested the review by Dr Stephen Duckett to:
Review the department’s current systems for governance and assurance of quality and safety in hospitals; and
Where systems were found to be inadequate, to provide advice as to how these systems may be improved. 
Despite the incidents occurring at Djerriwarrh health service, these are considered to be symptoms of a broader problem. The review is revealing, enlightening and comprehensive and will affect all hospital and health care services.  The recommendations are many, and about serious change. 

Major deficiencies addressed
It was found that the department’s oversight of hospitals is insufficient. It was also found that the department does not have the information it needs to assure the Minister and the public that all hospitals are providing consistently safe and high-quality care (DHHS, 2016). 
The major deficiencies in health care that have been identified and addressed by this review, along with the related NSQHS are as follows:
1.A lack of reporting errors and adverse patient events. This was made evident due to the finding that the department “does not have a functional incident management system for hospital staff to report patient harm” (DHHS, 2016, p13). Complaints of the system are that The Victorian Health Incident Management System (VHIMS) is difficult to use, poorly designed and excessively complex. For example, the current “incident classification component of the system has more than 1400 different types of incidents that users need to select from, making selecting an appropriate classification time consuming and complex. This also means that users may classify incidents inappropriately or select generic classifications like ‘other’ to save time” (DHHS, 2016, p107).  It was found that all reports related to the tragedies at Djerriwarrh were not made accurately or on time. However, regardless, it has also been identified that the department was not monitoring and analysing the incident database and so would not have detected them anyway (DHHS, 2016). “A dysfunctional incident reporting system means that potentially useful information about recurrent safety breaches is often unreported, misclassified or lost before it reaches the department” (DHHS, 2016, p14).  Additionally, it was found that the “departments performance monitoring framework is not designed to detect catastrophic failings” (DHHS, 2016, p13). 
The NSQHS that this major deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS, 2012). This particular standard has certain criteria that must be met in order to achieve this standard. One of which is about incident and complaints management, specifically, that adverse events are recognised, reported and analysed. It is clear from the deficiency identified, that this criteria has not been effectively met by Djerriwarrh or the department. 

2.The department’s expert committees are fragmented and many are not resourced to detect problems in a timely manner or to follow up to stop them happening again (DHHS, 2016). Additionally, cultural barriers to reporting have been identified (DHHS, 2016). For example, it was found that staff complaints were discouraged, ignored, or dismissed. It was also found that both internal management and regulatory oversight either did not detect the problems or failed to address them (DHHS, 2016). 
The NSQHS that this deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’. The particular criterion that has been breached in relation to this standard is related to incident and complaints management. It is clear that patient safety and quality incidents were ignored and clearly were not reported correctly, analysed and thus not used to improve safety systems (NSQHS, 2012)(Miller, 2013). 

3.The department has over-relied on accreditation when the evidence suggests that is not justifiable (DHHS, 2016). For example, Djerriwarrh Health Services was consistently identified as a high performer, gaining top scores at the end of 2012-13, and it was found that the department had no concerns until early 2015, at which point seven potentially avoidable deaths had already occurred. A series of factors contributed to this failure however, poor clinical governance is to blame and ultimately the department had over-relied on accreditation. Disturbingly, this clinical governance failure at Djerriwarrh was found to be a risk that could easily occur at any hospital or health service (DHHS, 2016). 

The NSQHS that this deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’. This particular standard has certain criteria that must be met in order to achieve this standard. One of which states the necessity for implementing a governance system that undertakes regular clinical audits (NSQHS, 2012). This has clearly not been effective as if regular effective audits were undertaken, then the failure in clinical governance would have been identified. 

4.The department is lacking in the use of routine data that has been collected in order to monitor hospitals’ complication rates (DHHS, 2016).  Clinicians and hospitals cannot access critical information as essential data is not collected or is not made available in a convenient form. Additionally, it was found that much routine data is collected, however the department does not access it often enough to monitor patient outcomes and investigate red flags. Within routine datasets, the department has failed to fully access and use detailed information on hospital-acquired complications meaning cases of underperformance have been missed. 

The NSQHS that this deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS, 2012). A criterion of this standard is related to governance and quality improvement systems, stating that there must be integrated systems of governance to actively manage patient safety and quality risks (NSQHS, 2012). Clearly, the department has failed in this aspect as red flags and cases of underperformance have gone unnoticed, subsequently placing patients at risk. 

5.In the public sector, the department expects and relies too heavily on hospital boards to ensure care is safe and continuously improving (DHHS, 2016). The department also does too little to ensure that all boards are equipped to exercise this function effectively (DHHS, 2016). This is a reflection that the department’s overarching governance of hospitals is inadequate. It has been found that the department was not placing enough priority to patient safety. The review discusses in detail the disparities within hospital boards between small and large hospitals, differing opinions of CEOs and financial teams, however that is not the scope of this essay. The bottom line is, that the department was not doing enough to be involved with, understand and even pick up on these disparities, at the expense of patient safety and continuous improvement in health care.
The NSQHS that this deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS, 2012). There are two criterion to meet this standard that have been breached. The first one is that of governance and quality improvement systems.  Integrated systems of governance to actively manage patient safety and quality risks has clearly been breached in this respect. Additionally, the criterion of incident and complaints management has also been breached as patient safety incidents are not recognised, reported and analysed at all levels of the healthcare system. 

6.Similarly, to point number six, in the private sector, the department relies even more heavily on local governance (i.e. hospital boards) to ensure that care is safe and continuously improving (DHHS, 2016). It was also found in the private sector that the department conducts no routine monitoring of patient outcomes or serious incidents (DHHS, 2016). Currently, private hospitals are not subject to the same reporting requirements as public hospitals, and almost no data is collected, monitored or fed back to private hospitals about their safety performance. 

The NSQHS that this deficiency relates to is standard number one ‘Governance for Safety and Quality in Health Service Organisations’ (NSQHS, 2012). Similarly to point number six above, two criterion to meet this standard have been breached. The first one is that of governance and quality improvement systems and the other is the criterion of incident and complaints management (NSQHS, 2012). 
In both sectors, the department could and should be doing much more to ensure that hospitals do not provide care when it is outside their capability to do so (DHHS, 2016).

7.The department has not been supportive enough of hospitals and has provided too little leadership in respect to safety and quality improvement (DHHS, 2016). It was found that the department has not offered continuous support or sustained investment in the right resources that hospitals need.  Hospitals are often left to create their own approach to safety and quality improvement, leading to duplication of work, variation in quality and inefficiency (DHHS, 2016). It was also found that high quality information is not being developed or shared and therefore, hospitals are not able to learn from each other. Ultimately, the department is not offering a strong enough system and is not offering the right resources, information and incentives for hospital clinicians and executives to offer the best possible care. Additionally, it was found that there is a lacking in communication between external expert bodies and the department regarding the sharing of information, and more prominently, the identification of unsafe practitioners (DHHS, 2016). 
The NSQHS that this deficiency relates to is ‘Governance for Safety and Quality in Health Service Organisations’(NSQHS, 2012).  Two criterion to meet this standard have been breached. The first one is ‘clinical practice’. This criterion states that care provided by the clinical workforce must be guided by current best practice. Clearly, if hospitals are developing high quality information, but this is not being shared between hospitals, then it is not likely that all clinicians are operating under current best practice.
The second criterion that has been breached is ‘governance and quality improvement systems’(NSQHS, 2012). This criterion states that ‘there must be integrated systems of governance to actively manage patient safety and quality risks’. The departments overarching governance in terms of providing necessary resources to hospitals and clinicians has been inefficient.

In a broad sense, it is likely that the department’s deficiencies relate to all of the current NSQHS standards. These include preventing and controlling healthcare associated infections, medication safety, clinical handover, blood and blood products, preventing and managing pressure injuries, recognising and responding to clinical deterioration in acute health care and preventing falls and harm from falls (NSQHS, 2012). Ultimately, however, they all come down to a major deficiency in clinical governance. The review defines clinical governance as the “systems and processes that health services need to have in place to be accountable to the community for ensuring that care is safe, effective, patient-centred and continuously improving” (DHHS, 2016, p3). The review found that the department’s processes, at Djerriwarrh, and more broadly, all hospitals, were not capable of detecting significant deficiencies in clinical governance. 

Additionally, these deficiencies and issues with clinical governance are not isolated to Victoria. A literature review found many articles outlining similar problems within health care systems relating to clinical governance and quality and safety of patient care (Atsalos, O'Brien, & Jackson, 2007; Robinson, Travaglia, & Braithwaite, 2008; Tuan, 2015). In Victoria, it has been suggested that the health care system does not require major reform (Duckett, 2008). It is acknowledged however, that change is required at a macro level in the roles of Commonwealth and state governments and on a micro level, amongst health care providers (Duckett, 2008).

Part two - change management
It is clear from the analysis of Stephen Duckett’s review that major change, with the immediate focus of health care concerns, within the department is dearly necessary. Change is a necessary part of health care. Change is influenced by both external and internal factors and is required to adapt and align the organisation with new realities that are constantly emerging (Kumar, Kumar, Deshmukh, & Adhish, 2015). For example, technological advances, demand for quality assurance, epidemiology of diseases emerging and re-emerging, era of evidence based policy, health and medical care, privatisation and commercial interests and health as a human right (Kumar et al., 2015). In summation, for an organisation to survive, it must adapt to changing conditions. 
Change is not an easy thing to implement or carry through, especially in a long lasting way. Organisational change “requires personal change in an organisational setting” (Carlopio & Andrewartha, 2008, p.496). A lot of people are resistant to personal change. It takes effort, persistence and time. Often there can be a sense of loss as old ways of doing things become redundant, however with change we adapt, learn and grow. 
Research has shown that healthcare sectors often experience challenges associated with implementing change effectively (Allen, 2016). These challenges include difficulty in motivating employees to change, communicating the need for change effectively and sustaining any improvements that the change has achieved over time (Martin, Weaver, & Currie, 2012). It is recognised that the complexity of the health care system that makes the process of change most difficult (Allen, 2016). 
Change can refer to macro change and micro change. In respect to health care and the Victorian health care system, macro change can refer to overall change in the health care system, or at an organisational level. Micro change can refer to a specific work unit or department. In respect to the Victorian health care system, macro change is needed at the overall health care system level, starting with the department. This will hopefully create a ripple effect right down to the micro changes in service delivery and bedside care. All of these changes however require proper change management (Currie & Loftus-Hills, 2002; Kumar et al., 2015).

Change Process 
To increase the likelihood that organisational change will be effective, it would help if nurses and other health professionals have knowledge of theories and models of change (Mitchell, 2013; Price, 2008). This is especially applicable to managers and particularly leaders within the health care setting as these are the people who will most likely be instigating and implementing the change.
There are a multitude of theories that can be used to implement organisational change (Allen, 2016; Freshwater, 2014). There are two models, however that appear to be most applicable to implementing change in health care. Most contemporary theories and models are adaptations from the work of Kurt Lewin (1947) and his classical three stage change model. John Kotter (1996) however, created an eight step change model based on Lewin’s three step process that has been identified as successful (Kumar et al., 2015). Both models have been summarised below, however it is Kotter’s (1996) model that will guide the reader in how a plan could be implemented to improve the reporting culture on a ward based around safety concerns.  

Part 1

Introduction

The contemporary healthcare system in Australia is witnessing major challenges while delivering optimal quality healthcare services. Across all health systems, patient harm and variability in care services are prominent despite the fact that concerted efforts are being put forward. The blame is to be given on ineffective systems that indicate insufficient knowledge and lack of governance and leadership (Lane et al., 2017). The Victorian Government’s Department of Health and Human Services released a review report titled Targeting zero: Supporting the Victorian hospital system to eliminate avoidable harm and strengthen the quality of care. Report of the review of hospital safety and quality assurance in Victoria’, that addressed the issue of hospital safety and quality assurance in Victoria. The review was undertaken by Dr Stephen Duckett, Director of the health program, Grattan Institute. The review was responsible for carrying out a rigorous examination of the extent to which the departments had sufficient systems for ensuring safety and quality of care delivery. It also aimed at providing suitable recommendations regarding how significant improvements could be brought about for achieving modern-day best practices as highlighted by international bodies and jurisdictions. The scope of the review was aligned with the objective of undertaking an assessment of the systems of the department providing all in-hospital care in both the public and private sectors (Duckett, 2016).

The present section of the paper is focused on highlighting the major healthcare deficiencies addressed by the review under discussion. In addition, it brings into limelight the National Safety and Quality Health Service Standards (NSQHSS) that these deficiencies relate to.

Major health care deficiencies addressed by the review

National health care policies of Australia are looked after by the Australian Government who is under constant pressure to come up with novice strategies to address pressing issues. At the ground level, Australian Government is mainly responsible for public and community health. In Victoria, the Department of Health and Human Services is accountable for this role. Understanding that the contemporary healthcare system of Victoria is not up-to-the-mark, the Australian Commission on Safety and Quality in Health Care (ACSQHC) was entrusted with the task of carrying out an independent review that would highlight the critical issues faced by the department. The review by Stephen Duckett has been successful in identifying a certain number of deficiencies and addressing them throughout the review. These deficiencies relate to the inability to control the management system of the hospitals. In addition, there was a concern of insufficient information for assuring that high quality and safe care is being provided consistently (Canaway et al., 2017). The National Safety and Quality Health Service Standards are eminent in providing nationally consistent and uniform set of measures of safety and quality that are to be applied across health care services. The deficiencies highlighted in the review and the corresponding NSQHSS they relate to are to be elaborated as follows-

Lack of leadership

The key issue that the review highlighted was lack of adequate clinical leadership. The department is to be accused of not exercising adequate leadership that holds the potential to guide improvement initiatives (Duckett, 2016). The review highlighted that there is a dearth of support provided from the department’s end that leads to lack of sustained investment in the appropriate resources. Leadership ensures that all healthcare settings under a certain department are linked through a common set of objectives for achieving the same goal of optimal care services. However, in the present case, the department was found not to adhere to this principle and leave the hospitals on their own to create an approach towards quality improvement that is not sufficient. In addition, no leadership approach had been taken for sharing quality information between hospitals regarding improvements made. Had there been sharing of information between different settings, one could have learnt from te mistakes of others and avoided the same. Further, a lack of communication between the department and external bodies added to the issue.

According to Grohar-Murray et al., (2016) the importance of leadership in the healthcare sector is increasingly being felt at present. Healthcare facilities are a unique environment where the prime priority is to care for the patients. For translating this mission into practice, it is the responsibility of the concerned healthcare departments of the countries to demonstrate suitable leadership skills and be in a position to be responsible for the challenges faced.  Since multiple healthcare settings work under a particular department of health, leaders from the department must establish a strong collaborative relationship amongst the different settings, so the work process is smooth. Such a relationship ensures cooperation between hospitals that enables the exchange of health information (). Leadership is imperative for handling pressures on service provision, improving ways of working and addressing failures in care delivery.  

The issue of lack of leadership is related to the NSQHS Standard 1 “Governance for Safety and Quality in Health Service Organisations” (NHQHS, 2012). As per this standard, all health care department must follow a quality framework for implementing safe care systems. It is elementary for health care departments to exercise governance and leadership traits that bring improvement in the performance of all organisations working under it. Such improvement can be brought about when information on patient experience is exchanged between settings. The two criteria for achieving the governance for safe and quality are ‘Governance and quality improvement systems’ and ‘clinical practice’. The first criteria relate to the integrated system of governance and leadership that can manage risks in patient safety. The second criteria relate to use of best evidence for solving clinical issues. In the present case, the Victorian health department is to have overarching governance for providing sufficient resources and establishing a connection between the concerned hospitals.

Adverse patient events remaining unreported

The review highlighted that patient events, and errors are not being reported adequately, giving rise to a significant issue. The findings were that the department did not possess a robust functional incident management system that could encourage hospital employees to report any incidents of patient harm (DHHS, 2016). The challenges that came into the limelight was that extremes difficulties were faced while using The Victorian Health Incident Management System (VHIMS). The reason for this was the poor designing of the system and highly complex nature. An example that can be cited in here is the concern prevailing regarding the incident classification element of the system as it has 1400 categories under it. Such an in-detailed classification makes the process complex and highly time-consuming. Classification of the incidents is therefore inaccurate. It was highlighted that the tragedies that took place at the Djerriwarrh were not reported in a timely manner and were also inaccurate. In addition, the department’s performance monitoring framework was not suitable for detecting failings that were catastrophic.

As highlighted by Pham et al., (2013) an incident reporting system that is dysfunctional restricts the exchange of valuable information that pertains to recurrent breaches in safety guidelines. The authors also stated that adverse patient incidents are to be identified at the earliest so that such situations can be avoided in future. It is common for healthcare organisations to make errors in the due process of delivering care. What is of more importance is that such incidents are to be reported timely so that strict actions can be taken in future.

The above mentioned deficiency relates to the the NSQHS Standard 1 “Governance for Safety and Quality in Health Service Organisations” (NHQHS, 2012). The criteria for achieving the governance for safe and quality is ‘incident and complaints management’. As per this standard, any complaints regarding safety guideline breach is to be reported by the professionals. All organisations must ensure that undesirable incidents are identified, reported and analysed thoroughly.

Unjustified dependence on accreditation

Over-dependence of the department on accreditation was highlighted in the report. There was an indication that healthcare services such as the Djerriwarrh Health Services had been consistently given the accreditation of high performer as it gained high scores at the end of 2012-2013. The department, therefore, did not think it important to consider revising the accreditation until 2015 when a number of avoidable patient injuries occurred. It was only until such incidents of patient death occurred that the department reviewed the overall impact of the accreditation. The key attributes resulting in the failure to uphold proper accreditation were poor governance and supervision. Regular audits were not undertaken as identified by the report (Duckett, 2016).

Clinical audits are a central part of operations for any healthcare organisation as opined by Hamer and Collinson (214). The authors highlight that clinical audit acts as a quality improvement process seeking to bring improvements in the quality of patient care through systematic reviews undertaken a set of explicit criteria. It is fundamentally a way of understanding whether the service being provided is aligned with the particular standards and whether high ratings can be conferred on to them.

The above mentioned deficiency relates to the NSQHS Standard 1 “Governance for Safety and Quality in Health Service Organisations” (NHQHS, 2012). As per the criteria of ‘governance and quality improvement systems’, all healthcare organisations must have an integrated system of governance. Through a systematic approach, quality improvements can be brought about. Governance in this respect would refer to regular clinical audits being undertaken for assessing the progress made by the care organisations and any deviation from the standard guidelines.

Inferior expert committees

The review report identified that the expert committees of the department are not linked with each other and that there is an issue of inadequate resource allocation (Duckett, 2016). The report highlighted that the expert committees did not consider cultural barriers while addressing care delivery and at the time of finding resolutions to clinical issues. An example of such poor practice was that the complaints of the patients were not registered adequately and a certain proportion of the complaints were dismissed or ignored. In addition, the committee was not successful in detecting factors that led to major regulatory and management issues considering internal affairs.

Dunn (2016) opined that expert committees are responsible for focusing on different issues that emerge time and again in a healthcare setting requiring continual attention. Having a fragmented expert committee is not justified, and this is more evident when resource allocation is not sufficient for detecting problems. Such a committee must be equipped with resources to prevent undesirable issues from happening again.

The above mentioned deficiency relates to the NSQHS Standard 1 “Governance for Safety and Quality in Health Service Organisations” (NHQHS, 2012). As per the criteria of this standard focusing on ‘performacne and skills management’, the clinical committees must be in a position to demonstrate a safe approach towards healthcare. In view of this criteria is required that the department establishes a committee that promotes high quality management system informing evidence-based changes in practice. Such practices are to be culturally safe.

Inadequate data reporting

Duckett (2016) in his report highlighted that the department had been lagging behind in collecting data on a regular basis that has the purpose of monitoring the complication rates arising within the hospitals. The author further highlighted that hospitals are not in a position to access a comprehensive set of up-to-date information that is critical for understanding major improvements made in the recent past. Even though data is collected, it is not disseminated in a convenient form, and the department does not show initiatives to access them and investigate all incidents of red flag. Failure has also been detected in the field of utilisation of information on complications arising within the case setting, implying that underperformance remained unreported.  

Denton (2013) reported that data reporting system and protocol is a fundamental part of healthcare system functioning in the absence on which professionals are not able to identify the changes required on an immediate basis. Sharing of information in a systematic manner ensures that the information is available at all levels of the organisation and anyone can identify underperformance.

The above mentioned deficiency relates to the NSQHS Standard 9 “Recognising and Responding to Clinical Deterioration in Acute Health Care” (NHQHS, 2012). As per the criteria of ‘Establishing recognition and response systems’, healthcare systems are to establish and adhere to a system that recognises any deviation from the standard practice.  For doing this regular data collection is needed which is to be reflected on for bringing in future changes in practice.  

Inappropriate dependence on local governance

The unnecessary dependence of the public and private sectors on local governance has been highlighted by Duckett (2016). The report pointed out that both the sectors have the tendency to rely on the local hospital boards when it comes to ensuring improved and safe care. In addition, the department does not take many initiatives for equipping the boards with resources necessary for safe practices. The fact makes the issue of the absence of governance more prominent. The review further discusses that disparities remain among the hospital boards as there are distinct differences between the viewpoints and opinion of the respective teams. The main point is that the department had little involvement in resolving the disparities. It has shown an inability to have an integrated system of governance leading to poor patient outcomes.

Grohar-Murray et al., (2016) argue that health departments of a country must hold supremacy in supervising the functioning of the different local boards of healthcare organisations. Though work is distributed among the different local governance bodies, delegating responsibilities and supervising them is important. Departments must support the local bodies and keep an eye on them to measure their effectiveness and success.

The above mentioned deficiency relates to the NSQHS Standard 1 “Governance for Safety and Quality in Health Service Organisations” (NHQHS, 2012). The criteria set by this standard that relate to this deficiency is ‘governance and quality improvement system’. As per this criteria, the department is to be proactive in ensuring compliance with set guidelines and communicating with the workforce on a regular basis. It is the responsibility of the department to maintain harmony between the boards of organisations and exercise leadership and power on them.

Conclusion

Divergence from best practice was the prime concern against which there was a necessity to review the situation for coming up with relevant strategies. The report put forward by Stephen Duckett was a key initiative to bring into focus the issues pertaining to governance and lack of knowledge in the Victorian healthcare departments. The background of this review report was marked by the fact that patients are subjected to harm and injuries while receiving care at the health care settings. The report was successful in looking into the manner in which the department manages the set of challenges emerging while delivering comprehensive care. Specifically, the concerned authority was accountable for considering authoritative and clinical issues pertaining to health care deficiencies. On the whole, the deficiencies pointed out by the review relate to the NSQHSS that focus on best quality health care systems. In view of the present situation, there is a need of implementing robust strategies that would bring improvement in this context. Change management theories can be useful in this regard as evidence-based practices are to be implemented. With suitable humanistic and strategic change management processes into practice, it can be hoped that much can be achieved within a short span of time.

Part 2

Introduction

Clinicians and the executives of the hospitals are unable to deliver the best possible care in the absence of a strong system with right pair of resources, information and proper financial support. The department of healthcare in unable the provide any of these factors to its health care executives and failing to d so has generated a strong set back in the Victorian health system. Here high quality information is neither shared nor developed. The department is also making poor use of the clinical existing data in order to drive for the quality improvement. The hospital system thus lacks proper leadership qualities, effective distribution of hierarchy and proper clinical information. This lack of data is hampering quality care (Duckett, Cuddihy & Newnham, 2016).

In order to work upon the health care deficiencies, several changes need to be implemented. This implementation of the change must be done via management principles while considering the theories of power. The following essay will describe how the change can be implemented into the hospital safety and quality assurance in Victoria under the light of three different theories, Kurt Lewin Change Model, Kotter;s Change Model and Weber theory of power.  

Kurt Lewin Change Model

The change model of Kurt Lewin is based on a three simple process that is unfreezing, change and freezing. It provides an advanced level of approach to change the overall system. This change model furnishes the manager a concrete framework to skilfully implement a change in an effortless, sensitive and seamless manner. The importance of the Kurt Lewin change model is to assist the leaders to perform three sequential steps in an organised way. These steps include: progress towards a radical change, minimal disruption of the structure which is under operation and proper adoption of the change in a permanent manner (Hussain et al., 2016).

According to the Kurt Lewin model, when a structure of an organization is operating for a while then habits and routines gradually settle in. May be the organization is going towards the right direction but the employees associated with that organization or the process involved in the organization might have strayed. The tasks, which are no longer relevant or useful in the present case scenario are still been executed as a result of habit and no one questions about the legitimacy of the work. The act of unfreezing means assess the present scenario (Hussain et al., 2016). While doing this, the organization must convince the employees that the change in the system is urgent and proper support from their end is imperative for the implementation of that change. In this step, the change or the systems which needs a complete revamp is identified and then frame a new plan to replace that change (Cummings, Bridgman & Brown, 2016). However, while in this process of revamp, discontent and disorientation might arise and therefore proper awareness is needed. After the changes have been identified then comes implementation of the new changes into the system via undoing old habits. This is known as moving stage where change agent identifies, plans and implements the change (Shirey, 2013). At this point, if the unfreezing stage is successful, then the driving forces should outnumber the restraining forces (Cummings, Bridgman & Brown, 2016). The process of change is dynamic and the employees within the organization need to undertake new responsibilities. However, the implementation of new changes into an existing organizational framework may slow the organization’s work process but it will benefit the organization in the long run (Shirey, 2013).  The changes can only be reflected in the organisation when the change made is permanent. This is done via cementing the newly evolved changes (refreezing) within the organization and getting people accustomed with those changes and compelling them to abide by the same.

According to Duckett, 2016 review paper, the healthcare department must adopt a goal of minimizing the variation in clinical practice in all hospitals (unfreezing). The implementation and refreezing of the goal will be undertaken via identification of the relevant clinical networks to frame specific strategies for best practice and must support the hospitals and the clinicians to implement this identified best practice. This best practise strategy should provide root cause analysis along with morbidity/mortality review protocols and will also undertake initiative to mandate the adherence of those protocols across the hospitals.  However, the protocol must be single protocol so that there remains a homology across the hospitals.

Nothing is constant in this universe expect the change and this change is unforeseeable. The present structure of the healthcare system is experiencing rigorous transformation and hence change in this sector is unpredictable, random and frequent. Kotter’s change model is popular in the business organizations. The popularity of the model is attributed for its easy adaptability and flexible incorporation of the responses of different staffs (Gupta, 2011). The concept of this change model is however, not popular in the healthcare sectors but if undertaken can provide effective framework for change implementation (Appelbaum et al., 2012).

The change model of Kotter has 8 different stages. The first stage is to create a sense of urgency. It helps in the fast movement towards the change for future development. This initial stage of the Kotter’s change model has been skilfully drafted to motivate employees of the organisation to garland the change. This motivation is done via emphasizing the urgent need for the change via highlighting the potential problems that can be dodged via the implementation of the change. Moreover, honest exchange of thoughts and ideas via discussion and delivering dynamic and reliable reasons will indulge people to sense the need for the change and act accordingly (Appelbaum et al., 2012; Gupta, 2011). Leadership development is crucial for the people heading the top positions in the hospitals like middle managers, clinical divisional directors, quality managers or directors. So, the nurse unit manager (NUM) or the change agent must show these professionals that how good leadership qualities will help in the skillful execution of the work process (Duckett, Cuddihy & Newnham, 2016).

Step two of the model is building a good coalition in order to convince people to welcome the change. This step must include the leaders of the organization so that they can convince the subordinated to adapt the change for the betterment of the organisation (Appelbaum et al., 2012; Gupta, 2011). For example the change manager must explain the leaders of the about the importance of the departmental leadership and how it can help in the improvement of the safety and quality of the healthcare (Duckett, Cuddihy & Newnham, 2016).

The third step is vision for change it will help people to easily grasp changes and implement it accordingly. It is also crucial to frame the initiatives firmly to achieve that vision and to able to communicate the change in large (Appelbaum et al., 2012; Gupta, 2011). The aim of this step of the change the plan to uplift the leadership quality of the higher authority professionals of the health care unit and the guiding vision can be extracted from the recent experiences, feedbacks form the patients and staffs and the literatures (Duckett, Cuddihy & Newnham, 2016).

The fourth step is to communicate the vision with the individuals who are assigned to execute the plan. The main points that should be communicated include how the changes can be done and why the changes are being implemented (Appelbaum et al., 2012; Gupta, 2011). In order to communicate the vision, the managers of the healthcare sectors who are instructed to enrol under leadership training program will be enlighten about the vision of the leadership training. Explanation will be given regarding how leadership training will help in the improvement of their traditional style of leadership and how this traditional leadership style will help in the improvement of the system (Duckett, Cuddihy & Newnham, 2016).  

The fifth step of the model is enabling action via removing barriers. Here via removing the barriers means removal of the insufficient processes which are blocking the path of the change execution. Such barriers can be anything including hierarchy or other unwanted workload, stress and lack of time management (Appelbaum et al., 2012; Gupta, 2011). To achieve proper leadership quality, the team members or the managers could be empowered to offer their own suggestion regarding the barriers of controlling a team and the same and be improved and this will help in reframing the leadership training plan. However, if should be keep in mind that while taking suggestion, anonymity should be maintained and the comments must be collected in the submission box (Duckett, Cuddihy & Newnham, 2016).

Sixth step of the change model is to generate short term wins. Highlighting short term win helps in generating momentum of the framed changes and this increase the amount of participation of the employees of the organisation. It will also motivate them (Appelbaum et al., 2012; Gupta, 2011). For example, the participation of the employees in the leadership training programs can be increased if the participants are awarded with small tokens if their teams perform better or achieve some desired target within the estimated time frame (Duckett, Cuddihy & Newnham, 2016).

The seventh step of the model is sustain acceleration. According to the concept of sustained acceleration, it is necessary to push for tougher goals after the achievement of the success in the initial stage. This push towards excellency will help in the improvement of system, structure and policies. The concept instructs to be relentless via initiating back to back changes until and unless the vision has been achieved (Appelbaum et al., 2012; Gupta, 2011). To implement the same concept on the ward, the team acting for the change should be always active and encourage the staffs to keep the entire change of vision under prime focus. Moreover, in order to push for excellency, the managers must be encouraged or rather instructed to participate in the special clinical leadership training program. This program will promote patient safety and quality care. The fundamental programs for the clinicians and the managers will be developed via local health districts. Here the participants will undertake a work-based improvement along with learning about the process of clinical leadership (Duckett, Cuddihy & Newnham, 2016).

The last and the final step of the change model is institute change. It means articulation between the new behaviours and organization success while making sure that they continue to be strong enough to replace the old habits which are polluting the environment. This 8^th step is critical for long term success as the new change or modification are prone towards degradation in front of the pressure of alleviated change and hence cementing of the changed reform in periodic manner is required (Appelbaum et al., 2012; Gupta, 2011). In order to implement this last step of the Kotter model in the ward, the change implemented via changed leadership skills should be taught to the new mangers and the floating staffs. This will help the change to become the foundational in the unit identity and thus will become an inherent part of the ward and the system process (Duckett, Cuddihy & Newnham, 2016).

No change can be introduced into a system without the application of theory of power and power holds equal share of importance in an organisation. Each designation in an organisation has certain power and share of responsibilities and according to this responsibility people work accordingly. An organisation having structure hierarchy is bound to perform in an organised way and is sure to achieve the desired target within the estimate time frame.

The theory of power, and how it affects the workflow of an organization can be explain via Weber theory of power. Weber theory of power is popularly known as three-component theory of stratification or Weberian stratification or three class system (Lenski, 2013). The theory has been named after the founder, Max Weber, a German sociologist. According to this theory, the three components of stratification are class, status and power. It gives a multi-dimensional approach towards the concept of social stratification that skilfully reflects the complex interrelation among the prestige, wealth and power.

According to Weber, there are two basic dimension of power and these are possession of power and execution of power. The possession of power is individual's ability of control and co-ordinate several "social resources". This mode of distribution of possession gives rise to monopoly on the chance of sharing or transfer of the owned resources. Here resources are known as wealth or capital. Exercising power means, ability of exercise or execute power in different forms (Weber, 2009). The strict distribution of hierarchy affects the flow of the work, creating a chance conflict. But proper distribution of hierarchy is required for the execution of the work flow in an organisation.

According to Duckett, 2016, creation of hierarchical division and separate offices are associated with several benefits. Firstly, creation of a separate office helps in raising the bar of safety and quality across the entire department. The main structure will no longer remain as a third order function as in the present structure of hierarchy, the chief executive officer will directly report to the secretary. The second benefit of this model is quality improvement in a co-ordinated manner. When number of networks, councils and committees work on same speciality domains across different department, fragmentation of accountability occurs. This gives rise of poor aligned area of focus. Centralization of model ensures complementary goals. Third benefit of the model is standardisation of approaches for quality improvement. This will be executed within the department so that the work of the clinical networks can start from the common base. Moreover, creation of high-profile office will ensure quality improvement. Here networks will run successfully, adapted under the ongoing programs and people will work within their defined key regulatory areas leading to increase in the productivity and decrease in the work related error. According to the Victorian Paediatric Clinical Network, the current structure of the clinical network fails to address the sustainability of the improvement activities in an adequate manner. The improvement in the sustainability can be effectively addressed via departmentalization of the program area.

Conclusion

Thus from the above discussion it can be concluded that application of Lewin three step model will promote large organisational change while Kotter eight step model will provide more comprehensive structure to implement changes in the Victorian health care model. Apart from these two models of change, there is another model of power, Weber theory of power. Via implementing Weber theory of power, the hierarchy of the organisation can be revamped and thus will further reduce conflict and will promote sharing of the responsibilities and power. The vigorous oversight in the system will prevent worst failures in care and will make Victorian hospital system a place of excellence. The boarder change in goal of the entire healthcare setup will help to achieve the goal.

References

Appelbaum, S. H., Habashy, S., Malo, J. L., & Shafiq, H. (2012). Back to the future: revisiting Kotter's 1996 change model. Journal of Management Development, 31(8), 764-782.

Canaway, R., Bismark, M., Dunt, D., & Kelaher, M. (2017). Public reporting of hospital performance data: views of senior medical directors in Victoria, Australia. Australian Health Review.

Cummings, S., Bridgman, T., & Brown, K. G. (2016). Unfreezing change as three steps: Rethinking Kurt Lewin’s legacy for change management. human relations, 69(1), 33-60.

Denton, B. T. (2013). Handbook of healthcare operations management. New York: Springer.

Duckett, S., (2016). The Report of of the review of hospital safety and quality assurance in Victoria. Melbourne: Victoria. Retrieved from: https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/hospital-safety-and-quality-review

Duckett, S., Cuddihy, M., & Newnham, H. (2016). Targeting Zero: Supporting the Victorian Hospital System to Eliminate Avoidable Harm and Strengthen Quality of Care: Report of the Review of Hospital Safety and Quality Assurance in Victoria. Victorian Government.

Dunn, R. (2016). Dunn and Haimann's Healthcare Management. Health Administration Press.

Grohar-Murray, M.E., DiCroce, H.R. & Langan, J.C., (2016). Leadership and management in nursing. Pearson.

Gupta, P. (2011). Leading innovation change-The Kotter way. International Journal of Innovation Science, 3(3), 141-150.

Hamer, S., & Collinson, G. (2014). Achieving Evidence-Based Practice E-Book: A Handbook for Practitioners. Elsevier Health Sciences.

Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2016). Kurt Lewin's process model for organizational change: The role of leadership and employee involvement: A critical review. Journal of Innovation & Knowledge. https://doi.org/10.1016/j.jik.2016.07.002

Lane, R., Halcomb, E., McKenna, L., Zwar, N., Naccarella, L., Davies, G. P., & Russell, G. (2017). Advancing general practice nursing in Australia: roles and responsibilities of primary healthcare organisations. Australian Health Review, 41(2), 127-132.

Lenski, G. E. (2013). Power and privilege: A theory of social stratification. UNC Press Books.

National Safety and Quality Health Service Standards. (2012). Retrieved from https://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf

Pham, J. C., Girard, T., & Pronovost, P. J. (2013). What to do with healthcare incident reporting systems. Journal of public health research, 2(3).

Shirey, M. R. (2013). Lewin’s theory of planned change as a strategic resource. Journal of Nursing Administration, 43(2), 69-72.

The 8-Step Process for Leading Change - Kotter International. (2017). Kotter International. Retrieved 25 October 2017, from https://www.kotterinternational.com/8-steps-process-for-leading-change/

Weber, M. (2009). From Max Weber: essays in sociology. Routledge.