Clinical leadership and alliance governance for whole of system improvement
An extract from an Interact webinar delivered on 22 September 2016 by Professor Robin Gauld, Co- Director, Centre for Health Systems and Technology; Pro-Vice-Chancellor and Dean, School of Business, University of Otago, New Zealand. Professor Gauld is also Independent Chair of Alliance South, in the southern part of the South Island.
New Zealand has experimented widely with different forms of governance and service organisation, including top down and bottom up approaches. However, present sentiment is settling around partnership and network planning and service delivery models in a “whole of system” paradigm. This is a hybrid of a top down and bottom up approach, and an “alliance” model of governance supports this approach.
Different approaches to governance
There have been different forms of top down governance operating in New Zealand’s health system since it was founded in 1938.
The older model of corporate governance is one such model. This model of governance is performance oriented, characterised by hierarchies of control, has appointed membership with specific skill sets, limits public consultation to certain decisions or points in the decision making cycle, and has an “us” and “them” mentality – in that health care professionals will blame the Board for not understanding how professionals will work, and the Board will blame the professionals for not understanding and acting upon the organisation’s imperatives.
In New Zealand, there is also a model of devolved democratic governance. This model is where the majority of board members of a District Health Board are elected – rather than appointed. This approach to governance is unique to New Zealand’s health system. While intending to represent the needs of the communities, its elected and appointed members are accountable to government – not the voters. Additionally, this model does not necessarily produce the skill mix or knowledge base that is required to drive the high performance of large, big budget and complex organisations.
Top down approaches are aimed at competition, national purchasing and devolved democratic governance. The benefits of top down approaches, where organisations compete with one another to achieve organisation objectives, can be limited. Efforts of those working within an organisation would be better focused on partnering in order to share and leverage the different skills, investments and experiences of actors so as to drive improved outcomes for a community.
Bottom up approaches have been successful. In the 1990s a restructuring of New Zealand’s health system saw general practitioners working together in order to drive improved policy and purchasing outcomes.
Contemporary clinical governance is also a “bottom up” and horizontal approach to governance. Clinical governance is defined as, “…a system through which health organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”.
Clinical governance in practice is the organisational fuel for health care quality and health system improvement. It is based on the idea that everyone in the health organisation has two jobs – i.e., Improving the system of care, as well as providing care.
Successful clinical governance aims to include partnership with management, build trust across the organisation, reduce clinical variation, standardise processes where possible, and placing patients at the centre of service design.
Key features of a successful system of clinical governance includes:
· Involvement of health professionals (clinicians) in leading and improving the system for organising and delivering care
· Leadership by clinicians – Including clinicians stepping into leadership positions as well as leading by example and leading change
· A clinical workforce who are engaged and committed to service improvement in their organsiation and to better patient care
· Clinical oversight of the organisation.
An evidence base exists supporting the role of clinically trained leadership in clinical governance, including research by McKinsey/LSE in 2010 which shows hospitals with clinically trained leadership are more likely to have standardised processes in place, and better patient outcomes. This finding is also supported by a 2011 study of US hospitals.
A fourth model of governance exists, termed “experimental governance”. It incorporates both top down (vertical) and bottom up (hortizontal) approaches to governance.
Klein defines it as, “Instead of a top-down, hierarchical rule-based system where failures to adhere are sanctioned, or unregulated market-based approaches, the new governance school posits a more participatory and collaborative model of regulation in which multiple stakeholders, including, depending on the context, government, civil society, business and non-profit organisations, collaborate to achieve a common purpose. In order to encourage flexibility and innovation, ‘new governance’ approaches favor more process oriented political strategies like disclosure requirements, benchmarking and standard-setting, audited self-regulation, and the threat of imposition of default ‘regulatory regimes’ to be applied where there is a lack of good faith effort at achieving desired goals”.
Key features of an Alliance model of governance
The idea of an alliance is derived from the construction industry where different businesses and interests work collaboratively to achieve a common goal – i.e., to complete a project successfully, on time, and within budget. They help one another, and where relevant, share resources.
Alliances within the New Zealand health system exist across public health care providers within a geographic area (see Figure 1). There were initially nine pilot health alliances, aimed at implementing the Government’s2009 “Better, Sooner, More Convenient” care policy.
Since mid-2013, each Primary Health Organisation (PHO) has been required to enter into an Alliance with its respective District Health Board (DHB). Each PHO-DHB Alliance is a governance arrangement (or mechanism) aimed at:
· Working in partnership to improve health and health services for their population
· Developing a “whole of system” approach to service planning and delivery with services provided in the best place as clinically agreed
· Improving the patient journey, with the patient at the centre of all planning, thereby improving integration and reducing duplication
· Allocating resources where these will best deliver on the Alliance’s goals and service designs
· Building cross-sectoral clinical leadership and engagement.
Membership of an Alliance typically includes health professional and managerial leadership. It is comprised of people with a needed skill, rather than from the perspective of achieving representation from an organisation or profession perspective. It is important, however, for members to have the capacity to lead, influence and understand perspectives of professional colleagues, such as general practice, nursing, or a medical specialty. As an example, members of an Alliance may include the DHB and PHO CEOs and managers, GPs, specialists, nurses, allied health professionals, managers and/or health professionals from ambulance services and aged care residential services, Maori/Pacific leaders, patients and community representatives, and an independent Chair.
The Alliance also has its own infrastructure, including a management and program office team. It also requires a Charter to outline the rules of engagement (see Figure 2).
While contentious, the effectiveness of the Alliance, together with the ability of the Alliance to meet objectives requires existing organisations to pool DHB-PHO resources, largely from pre-existing ring fenced allocations. The Alliance needs the local flexibility to allocate these funds to agreed services and initiatives.
Alliancing offers an important mechanism for cross-sector clinical leadership for integration and innovation. While the model in New Zealand has not been fully tested, some results and initiatives are already being seen (see Figure 3).
While the process is messy, it is part of the transition to building clinically-led, “whole of system” approaches. This will need to be support into further developing “whole of system” measurement, which should galvanise Alliances and their activities in the future.
To view the webinar, visit RACMA Interact Webinar Podcasts / Vodcasts on the RACMA website, link: https://vimeopro.com/racma/racma-interact-training-program/video/199129211
 Source: Scally G, Donaldson L. Clinical Governance and the Drive for Quality Improvement in the new NHS in England. British Medical Journal 1998;317(7150):61-65
 Source: S Dorgan et al, 2010, Management in Healthcare: Why good practice really matters. London: McKinsey/LSE
 Source: A Goodall, 2011, Physician-leaders and hospital performance: is there an association? Soc Sci Med, 73, 535-9
 Source: Klein, A. 2008, Judging as nudging: new governance approaches for the enforcement of constitutional social and economic rights, Columbia Human Rights Law Review, 39 2008.
Last Updated on Wednesday, 12 April 2017 16:51