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OR2: Leadership

OR2: Leadership

There is now a substantial literature that identifies the importance of leadership in the implementation of improvements both at the systems level (Greenhalgh et al. 2004, Best et al. 2012) and at the practice level (Grol & Jones 2000, Grol & Grimshaw 2003, Grol et al. 2013).

There are different types of leadership relevant to CQI: transformational leadership, designated leadership, and distributed leadership. Both designated and distributed leadership are essential.  Leadership commitment to quality improvement is necessary for ‘health care to achieve and sustain the elusive goal of consistent excellence in safety and quality’ (Chassin & Loeb 2011:566).


Transformational leadership – style of leadership in which the leader identifies the needed change, creates a vision to guide the change through inspiration, and executes the change with the commitment of the members of the group (Business Dictionary)

Designated leadership – someone formally in charge of the change effort

Distributed leadership – professionals (and partner organisations) share responsibility for mobilising effort and delivery.

What to look for

* Changes are made vertically and horizontally - many changes at the care team level need senior management approval and support.

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.


Hospital to home: An integrated approach to discharge planning in a rural South Australian town+

Journal abstract

Reference: D. Bolch, J. B. Johnston, Lynne C. Giles, Cr. Whitehead, P. Phillips & M. Crotty 2005, Hospital to home: An integrated approach to discharge planning in a rural South Australian town, Australian Journal of Rural Health, vo. 13, pp. 91–96.

Objective: To produce safer and more integrated hospital discharge planning practices for older people living in rural and remote settings.

Goals (Aims): (i) implement a system of discharge planning appropriate for a rural and remote setting; (ii) meet the needs of older patients and their carers for safe, timely and effective discharge; and (iii) improve continuity of care across the hospital–community interface.

Design: Plan–Do–Study–Act framework using case note audit and focus groups.

Setting: Central Yorke Peninsula Hospital in South Australia.

Intervention: Range of communication strategies designed to improve discharge planning practices. Many cycles of PDSA occurred as the interventions were developed, monitored and subsequently refined.

Main outcome measures: Percentage of patients with documented discharge plan, Percentage of patients risk screened, Percentage of community health service provider referrals, Percentage of patients followed up within 10 days of discharge (data disaggregated Aboriginal vs non-Aboriginal).


Topic: Hospital discharge planning for older people

Issues: A total of 46% of non-Aboriginal patients and 7% of Aboriginal patients had a documented discharge plan at baseline, and risks were identified on the nursing care plan for 17% of non-Aboriginal patients and none of the Aboriginal patients. No timely follow up of any patients by hospital staff following discharge was evident from the case-note audit. Referrals to community health services were also poor, with only 27% of non-Aboriginal clients and 14% of Aboriginal clients referred to allied health services within 48 h. It was not possible to determine if patients were referred in a timely manner.

Approach: The PDSA cycles allowed extensive consultations with the following stakeholders: consumers, hospital staff and community service providers. GP involvement was important as GPs managed patient care in both the hospital and community settings. Extensive internal and external stakeholder consultation occurred through focus groups with staff, Aboriginal and non-Aboriginal consumers, project team and steering committee forums and informal communication. Consultation also incorporated stakeholder surveys and interviews.

Baseline data: Data collected at baseline included: A retrospective audit of patient case notes (n=104) for October 2001 to March 2002; separate focus groups for staff, Aboriginal, and non-Aboriginal consumers; [RO5] and semi-structured interviews with community health workers; questionnaires for local GPs. Qualitative data showed a high level of confusion amongst consumers about available community services following discharge and how these services could be accessed. Interviewed community health service providers (n=9) all raised issues about patient referrals, including low numbers of referrals, untimely referrals and poor documentation within referral forms. GP surveys (n=7) indicated that discharge planning was fair, with five respondents stating that patients could be discharged earlier if home services were.


Improvement Strategies: A new discharge planning framework was established. This included a redesign of the patient admission form to incorporate a risk assessment tool, and the development of case-note ‘flags’ to identify existing services provided. Referral processes to community-based services were streamlined and widely communicated. Central to the interventions was the notion that all members of the clinical team should take responsibility for discharge planning. Most initiatives combined practice and communication improvements, and dissemination of information was of key importance in decreasing confusion amongst stakeholders. Flip charts and information transfer packs, designed for use in the hospital environment, were adopted enthusiastically by community health care providers. Post-discharge communication was initiated, with a telephone call to all patients aged at least 65 years, and Aboriginal patients at least 45 years, within 10 days of discharge. Many of these interventions were simple, user-friendly tools designed to streamline internal and external communication processes. Baseline data showed discharge planning was poorer for Aboriginal patients than non-Aboriginal patients. One staff focus group member stated, ‘I want to find out risk factors and care for them [Aboriginal clients] but am often met with aggression.’ These issues required careful handling by the project team. Cultural awareness training was provided for staff, with the course designed to foster respect for cultural diversity. The employment of an Aboriginal liaison officer also contributed to progress in this area. Staff and non-Aboriginal focus groups also provided a forum for promoting cultural awareness.


Throughout the Study phase, monthly focus groups were held, and used to regularly monitor interventions in an open forum. These discussions were integral to the Act stage of the PDSA cycle. Based on the review of KPIs, some new interventions were generated during the project and existing interventions were refined.
The study phase of the project incorporated ongoing monitoring of four KPIs, namely:

  1. Commencement of the discharge plan
  2. Provision of timely and informative risk screening
  3. Timely notification of community providers
  4. Follow up of the discharge plan.

The importance of ongoing education was identified 4 months into the project when performance began to fall on several indicators. Prompt action by the project team resulted in subsequent improvement in most KPIs by the end of the project. Evaluation of interventions by the staff focus group in the Study phase resulted in multiple amendments to the nursing admission and risk-screening tool based on users’ experience in applying the tool in the clinical setting. The ongoing evaluation of the project also resulted in several new initiatives from the Aboriginal focus group, and these included raising of the Aboriginal flag outside CYPH. The non-Aboriginal focus group identified the need for an information pack for patients being discharged from hospital.

These KPIs were measured by case-note audit on a monthly basis and reviewed by the project team, focus groups, steering committee and lead site hospital. An initial improvement in all indicators was followed by reduced performance in early 2003, which led to intervention refinement (the Act phase).


The project was important and newsworthy in the local community. Establishing focus groups created a way for all stakeholders to contribute actively in the development of health services at CYPH. Their energy and interest were harnessed to support development, communication and sustainability of interventions. [champions]

The high level of involvement of the Aboriginal community through the focus group was also integral to the success of the project. One participant stated, ‘Previously Aboriginals did not feel comfortable in the hospital and did not feel that they were welcome, now we feel as if it is our hospital too’. Feedback from the Aboriginal community was very positive, with two sentinel comments being ‘I never thought I would see it [raising of the Aboriginal flag] in my life time’ and ‘It brings tears to my eyes to see it [the Aboriginal flag] flying.’ This [Aboriginal] consumer focus group is ongoing and provides both a sustained mechanism for consumer involvement and promotes strengthened relationships between the local Aboriginal community and the health services.

Some challenges were experienced in working within this rural and remote site. The high level of interest and ownership of the project meant that everyone wanted to ‘have their say’ and this often slowed down development of interventions. For example, the nursing assessment/risk assessment tool was modified 12 times following implementation as a result of staff feedback. Difficulties with access to information technology, administrative support, and competing workloads for the project officers were also limitations. Information technology was poorly supported with internet connections difficult to establish and maintain. The administrative infrastructure for the development of forms, questionnaires, tools and resources was not available on-site. A further challenge experienced by the project team was an ongoing requirement for the project officers to work additional shifts in the clinical setting due to nursing staff shortages.

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.