New Zealand Pae Ora Healthcare Reforms 2022: Viable by Design? A Qualitative Study Using the Viable System Model.

BACKGROUND: The New Zealand (NZ) Pae Ora (Healthy Futures) health reforms came into effect in July 2022 with the establishment of Health New Zealand (HNZ) (Te Whatu Ora) and the Maori Health Authority (MHA) (Te Aka Whai Ora) - the organisations charged for healthcare provision and delivery. Given these changes represent major health system reform, we aimed to conduct an early evaluation of the design of the reforms to determine if they can deliver a viable and sustainable NZ health system going forward. METHODS: The evaluation was informed by Beer's viable system model (VSM). A qualitative exploratory design with semi-structured interviews and documents analysis using thematic analysis was used. We conducted 28 interviews with senior healthcare managers and reviewed over 300 official documents and news analyses. RESULTS: The VSM posits that for a system to be viable, all its five sub-systems (operations; co-ordination; operational control; development and governance) need to be strong. Our analysis suggests that the health reforms, despite their strengths, do not satisfy this requirement. The reforms do appreciate the complexity of the healthcare environment: multiple stakeholders, social inequalities, interdependencies. However, our analysis suggests a severe lack of detail regarding the implementation and operationalisation of the reforms. Furthermore, resourcing and coordination within the reformed system is also unclear. CONCLUSION: The health system reforms may not lead to a viable future NZ health system. Poor communication of the reform implementation and operationalisation will likely result in system failure and inhibit the ability of frontline health organisations to deliver care.

What makes an effective Quality Improvement Manager? A qualitative study in the New Zealand Health System.

PURPOSE: Quality improvement is an international priority, and health organisations invest heavily in this endeavour. Little, however, is known of the role and perspectives of Quality Improvement Managers who are responsible for quality improvement implementation. We explored the quality improvement managers' accounts of what competencies and qualities they require to achieve day-to-day and long-term quality improvement objectives. DESIGN: Qualitative exploratory design using an interpretivist approach with semi-structured interviews analysed thematically. SETTING AND PARTICIPANTS: Interviews were conducted with 56 quality improvement managers from 15 (out of 20) New Zealand District Health Boards. Participants were divided into two groups: traditional and clinical quality improvement managers. The former group consisted of those with formal quality improvement education-typically operations managers or process engineers. The latter group was represented by clinical staff-physicians and nurses-who received on-the-job training. RESULTS: Three themes were identified: quality improvement expertise, leadership competencies and interpersonal competencies. Effective quality improvement managers require quality improvement experience and expertise in healthcare environments. They require leadership competencies including sense-giving, taking a long-term view and systems thinking. They also require interpersonal competencies including approachability, trustworthiness and supportiveness. Traditional and clinical quality improvement managers attributed different value to these characteristics with traditional quality improvement managers emphasising leadership competencies and interpersonal skills more than clinical quality improvement managers. CONCLUSIONS: We differentiate between traditional and clinical quality improvement managers, and suggest how both groups can be better prepared to be effective in their roles. Both groups require a comprehensive socialisation and training process designed to meet specific learning needs.

Why is Quality Improvement so Challenging? A Viable Systems Model Perspective to Understand the Frustrations of Healthcare Quality Improvement Managers.

The challenges facing Quality Improvement Managers (QIMs) are often understood and addressed in isolation from wider healthcare organisation within which quality improvement initiatives are embedded. We draw on Stafford Beer's Viable System Model (VSM) to shed light on how the viability of quality improvement depends on the effective functioning of five critical quality improvement systems and the extent to which these systems are integrated within the healthcare organisation. These systems are System 1 (Operations), System 2 (Coordination), System 3 (Operational Control), System 4 (Development) and System 5 (Policy). Our analysis draws on interviews with 56 QIMs working in 15 of New Zealand's 20 District Health Boards. We use VSM to identify the sources of problems in QI implementation. These include changes in direction for QI initiatives; myopic behaviour resulting from fragmented systems of care; difficulties in managing and monitoring QI activities given variable staff engagement and inadequate resourcing; pressure for quick results rather developing QI capabilities; and a lack of strategic embeddedness. A viable QI system requires QI approaches that are (1) implemented at an organisation-wide level; (2) well-resourced and carefully monitored; (3) underpinned by a long-term vision; and (4) supported by QIMs with the necessary power and influence to integrate QI subsystem within the wider healthcare organisation.