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OR1: Organisational culture for CQI

OR1: Organisational culture for CQI

For CQI, a participative, flexible, risk-taking organisational culture has been significantly related to quality improvement implementation in primary health care settings (Shortell et al. 1995).


A set of attributes that emerge from what is shared between colleagues in an organisation, including their shared beliefs, attitudes, values, and norms of behavior. It reflects "the way things are done around here" (Davies, Nutley & Mannion 2000:112).  

What to look for

Please read and discuss the short journal article synopses below. Your discussions should be guided by the following:

  1. Identify and briefly reflect on one feature of this OR that is clearly evident from this study. One example will be shown when you click 'show answer'.
  2. Identify one other feature of this OR that you think might be implied by the study.
Inpatient care to community care: improving clinical handover in the private mental health setting+

Journal abstract

Reference: S. K. Wood, A. K. Campbell, J. D. Marden, L. Schmidtman, G. H. Blundell, N. J. Sheering & P. M. Davidson 2009, Inpatient care to community care: Improving clinical handover in the private mental health setting, Medical Journal of Australia, vol. 190, pp. S144–S149

Objectives: To develop and test a standardised clinical handover discharge strategy for improving information transfer between private mental health hospitals and community practitioners.

Design, setting and participants: A quality improvement intervention using collaborative, iterative methods to develop a standardised discharge and outcome assessment strategy. 150 patient participants were consecutively recruited from two private mental health care hospitals in New South Wales between April and September 2008. Opinions of community practitioners and patients on the discharge process and discharge documentation were solicited by written questionnaires and telephone interviews.

Main outcome measures: Community practitioner satisfaction; patient satisfaction; documentation of discharge date at least 48 hours before discharge; faxing of discharge summaries to community practitioners within 48 hours of discharge; proportion of patients receiving a follow-up telephone call within 7 days or 14 days of discharge.

Results: Both community practitioners and patients believed the intervention was positive. Between Cycle 2 and Cycle 3, documentation of the discharge date at least 48 hours before discharge remained unchanged at 50%; the proportion of discharge summaries faxed within 48 hours of discharge went from 0 to 82% in Cycle 2 and fell to 65% in Cycle 3. Telephone follow-up of patients within 7 days and within 14 days improved by 10% and 6%, respectively, between Cycle 2 and Cycle 3.

Conclusions: A standardised discharge communication strategy improved the timeliness, content, and format of information provided to community practitioners. The intervention was well accepted by patients and providers.


Topic: Clinical handover in discharge planning in mental health

Background: In mental health, stigma, confidentiality and issues relating to competency for decision making […] increase the complexity of discharge planning. Although there are robust governance practices for clinical procedures in the private hospital setting, there are often limited structures to leverage improvements in coordination and communication across care providers, particularly in smaller private facilities. In both acute and community settings, poor communication is increasingly being identified as a factor in adverse health events and diminished safety and quality of care.

Issues: Local issues not specified.

Approach: [This] project sought to develop and test a standardised clinical handover strategy for improving information transfer between hospital and community-based providers using PDSA cycles. A collaborative approach was used [involving] executive support and clinical leadership to drive practice improvement within a time-limited process. Implementation of the project was managed by a project team composed of hospital and community health care providers and patient representatives (on the steering committee). The Steering Committee (made up of the two directors of clinical services, the medical director, a psychiatrist, a pharmacist, a GP, a Division of General Practice representative, a patient representative, a discharge coordinator [from both sites] and the project coordinator) provided the knowledge, skills and networks for reviewing current discharge clinical handover practice. An internal reference group consisting of senior clinical administrative executives, nursing and allied health representatives, pharmacists, CMOs and psychiatrists was set up.

Baseline data: [There was] a comprehensive needs assessment and diagnosis of the issues to be addressed. Community-based practitioners, including GPs, psychologists and psychiatrists, were surveyed for their needs relating to the discharge process (surveys were mailed, faxed, or handed out at continuing professional development seminars held at each site). Comparative clinical indicators (CCIs) were developed for the project from the information derived from this phase. A review of discharge practices [in two studies] revealed a disparate approach to discharge documentation and communication, with most patients given only a nursing discharge summary and a medication list. Monthly audits of discharge letters from visiting medical officers (VMOs) revealed that the rate of mailing to the referring practitioner within 14 days of patient discharge was as low as 50%. A lack of consistency and coordination was evident, and local general practitioners expressed their concern about inadequate provision of timely and appropriate information.


First action cycle: the first action cycle, implemented the process developed and negotiated in the [planning and development phase]. Ongoing promotion of the study was undertaken through letters to senior clinicians, reporting on the project at meetings, and dissemination of study materials (including posters in clinical areas). Initially, some CMOs were reticent to provide a definitive diagnosis on the discharge summary without consulting the specialist psychiatrist. This was overcome by providing clinicians with additional resources such as process flowcharts, checklists and posters listing DSM-IV categories. To assess the impact of these strategies, patients at each hospital were recruited by the discharge coordinator. For participants recruited to the study, a fax-back evaluation survey was included with the faxed discharge summary to be completed by their community practitioner. Second action cycle: Based on Cycle 2 data, refinements to discharge processes were made. These changes included expanding the use of the new documentation to all patients to minimise confusion between usual care and the care of study participants. This change may have also reflected the diffusion of practice and clinicians’ favourable opinion of the new documentation and processes. In addition, a psychiatrist’s discharge summary form was included, after requests by some psychiatrists to have the option of completing their discharge letter at or before discharge.

STUDY – see under Do – ACT above


Over the course of the project, we learnt valuable lessons; in particular, that many obstacles can be overcome through collaboration and negotiation. The key facilitators to the processes were executive commitment, organisation-wide focus on risk management, dedication by the multidisciplinary team to meeting their responsibilities in a timely manner, and the appointment of an experienced nurse as discharge coordinator. In addition, we found that aligning the regular reporting of discharge-related outcomes (CCIs) with organisational quality and safety key performance indicators supports sustainability and continued improvement. Our project allowed the development and testing of a negotiated, evidence-based communication strategy designed to promote patient safety and quality of care. This reengineering of systems and processes happened without investment in expensive information systems, although the business processes and systems were developed to allow easy migration to e-health systems at a later stage. Integral to the process has been determining practitioners’ and patients’ satisfaction with the clinical handover communication strategy with respect to timeliness, content and format.

For discussion

Please read and discuss the journal article synopsis/es below in order to:

  1. Identify and briefly reflect on one feature of this OR that is clearly evident from this study. One example will be shown when you click 'show answer'.
  2. Identify one other feature of this OR that you think might be implied by the study.