The report into systems and leadership within the Central Adelaide Local Health Network (CALHN) – including the Royal Adelaide Hospital and the Queen Elizabeth Hospital – gives a devastating assessment of a health service with “no shared definition of what good care is or looks like”, where “effective medical leadership is conspicuously absent” and where the medical culture is “rooted in a mid 20th century view”.

The report finds “a clear commitment of staff to providing high quality care for patients” and points out several “exemplar” services within the system – especially gynaecology, the burns unit and the intensive care unit.

However, “when pressed, the majority of staff interviewed from throughout the organisation were unable to meaningfully describe how they knew that their care was good”.

“Coordinated, coherent and effective medical leadership is conspicuously absent” in the system, the report says.

It also finds CALHN’s safety systems react to dangerous events rather than preventing them, medical staff are resistant to necessary change, appointments to senior medical positions are made on the basis of seniority rather than merit and patient feedback is not “taken seriously”.

The report – compiled by a team of independent health management, safety and quality experts – also finds:

• “A strong sense amongst many (staff members) who were interviewed that their preference would be for family members to have care provided elsewhere”
• “Little sense that people are held to account for quality of care or for their behaviours”
• “No meaningful reporting to staff, the public, or to patients on the quality of care provided”
• “No consistency and little robustness in how care is measured or assessed at the service level  (with some exceptions)”
• “A widespread lack of understanding of contemporary clinical governance at all layers of the organisation”
• “Limited formal or informal appraisal of the performance of staff and particularly of senior medical staff”
• “With some exceptions, the medical profession in both major CALHN sites (the Royal Adelaide and Queen Elizabeth hospitals) has to varying degrees resisted real change, instead retaining a culture which is rooted in a mid‐20th century view of  the  profession, of their relationship with the organisation and of care delivery.”
• “At the macro organisational level, the involvement of patients and carers is largely tokenistic and based on a set of compliance driven activities rather than a concerted effort to genuinely hear the patient’s voice.”
• Patient feedback is “not presented in a way which drives understanding and improvement of patients’ issues”.
• “In the absence of positive clinical leadership for creating safe, high quality care, and in light of recent events and the multiplicity of changes occurring, it is obvious that many clinicians have lost trust in the healthcare ‘system’.
• “The safety system appears to be reactive and focused on what goes wrong, rather than supporting risks to be managed ‘in flight’ so that things go right.”
• Patients “continue to observe a ‘them and us’ culture (with some notable exceptions at clinical service level) that despite CALHN’s stated position, the organisation is not living its espoused value that the patient is the priority”.
• “‘Improvement loops’ are often not closed and the sharing of lessons learned across the organisation is limited.”
• Without a clear “vision” from CALHN executives about delivering safe, high-quality care, “it is easy for staff to be overly optimistic regarding the quality of care they provide, and the degree of  person‐centredness of that care, with little supporting evidence”.

Despite this over-optimism about the system, however, the report says “it was also notable how few of the medical staff interviewed were completely enthusiastic in their willingness to allow their family members to be treated at CALHN […] A number described preferring to send their family members to the private sector or other public hospitals outside of the network”.

Moreover, a constant turnover of management positions has encouraged lower-level staff to “‘keep their heads down and get on with the job’ rather than engage in meaningful discussion about the organisation’s strategy and … improving the quality of care”.

The authors’ comments on change management will be particularly uncomfortable reading for the State Government as it rolls out its Transforming Health reforms, which have “created a reasonably high level of uncertainty and low levels of morale”.

…overt displays of anger and sometimes unprofessional behaviour.

In recent years, large-scale structural organisational change “has been a near constant feature across SA Health and its agencies” – yet “in practice services have remained largely unaltered” – and the frequency of changing priorities has been enough to “exhaust people”.

According to the report, staff lack confidence that any management team would be able effectively administer the amount of change currently occurring in central Adelaide health services – including the transition to the new Royal Adelaide Hospital, the roll-out of the troubled Enterprise Patient Administration System, the State Government’s Transform Health reforms.

Compounding these problems, the review finds “a lack of clarity about the roles and responsibilities for clinical governance at the Executive level” and the system has “not been well served” by the role and functions of the Chief Medical Officer – currently occupied by Professor Paddy Phillips.

And although SA Health has announced a leadership development program for its “top 100” leaders in Transforming Health “many senior clinicians have never been trained in management, leadership or change management” and there is “no stigma” to clinicians assuming someone else will take up “the mantle of change management”.

And “when effective medical leadership is absent, change is inevitably difficult, lacks traction and sustainability, and is often associated with overt displays of anger and sometimes unprofessional behaviour”.

Many doctors who were interviewed for the review reported that “theirs was a resistant culture, a culture which rewarded and encouraged stasis rather than genuine change and a culture which had failed to come to grips with the reality of a resource constrained system”.

However, there are some “clear exceptions” to the change resistant culture the report describes, “characterised by the effective leadership of doctors who as a result have been able to bring others to a shared view that change is both important and desirable”.

The 73-page report was the result of 60 interviews, focus groups with staff and stakeholders, more than 560 responses to a staff survey, attendance at safety and quality meetings and visits to clinical areas.

It recommends a shakeup of executive-level positions and clinical management roles in CALHN, as well as changing the focus of quality and safety in the organisation to “constant improvement” rather than “compliance”.

It also recommends closing“improvement loops” so that when adverse events occur, they are prevented in future, and that patient feedback is used to drive change.

Its authors stressed that the information received from SA Health staff and health stakeholders was “accepted as provided; time did not permit an independent investigation to validate all information or data provided”.

CALHN Chief Executive Officer Julia Squire said that since starting in the role in October 2015, “I have found there are times when CALHN’s functions, processes, leadership and culture have been called into question”.

“As our services are transformed, our safety, quality and governance functions also need to change to embrace contemporary health care models,” she said.

“This review was important to help us know what we need to do to establish and support a culture that focuses on learning, improvement and putting patients at the centre of our care.

“The review confirmed that, while our staff are dedicated to providing the best care for their patients, the support systems, functions and leadership required are inadequate for our needs now and into the future.”

She said that the report “highlighted that there has been a lack of stability in clinical leadership for a contemporary service”.

“Whilst this is changing, it is something that we must continue to address for the benefit of both staff and our patients,” she said, adding that SA Health accepted the recommendations of the report in full.

CALHN is “developing a staged implementation plan, with engagement from our staff and consumer representatives,” Squire said.

“One of the key tasks will be implementing a new clinical leadership structure that will include key doctors, nurses and allied health professionals from across CALHN who will be supported by a new Executive Director of Medical Services.

“We are also reviewing how we manage adverse incidents and will develop an organisation-wide approach to establishing patient safety initiatives that can improve health outcomes.

“This is not an overnight solution, but rather a long term commitment by Central Adelaide Local Health Network, to provide sustainable health services that patients, staff and the community can value and trust.”

You can read the full report here.