01 February 2019

Unhealthy Workplace

The Interim Report of the Independent Review into the Workplace Culture within ACT Public Health Services finds - no great surprise - that the culture in the Territory's public health services is not very health; in deed at times it is quite toxic.

The Interim Report states
 In September 2018, the ACT Minister for Health and Wellbeing, Meegan Fitzharris MLA issued a statement on workplace culture which committed the ACT Government to an independent review of the culture within the public health services. This report is the Interim Report, with a final report due before the end of March 2019. The purpose of this report is to present initial high-level findings and a range of recommendations to support improvements to the workplace culture across the ACT Public Health System. 
The Review operated in accordance with the following Terms of Reference: 
a) Examine and report on the workplace culture of public health care services in the ACT and provide advice on any systemic and institutional issues. This examination should take into account any examples of best practice workplace culture and professional conduct in the delivery of public health care in the ACT, nationally and internationally. 
b) Examine any claims made in relation to inappropriate conduct and behaviours related to the delivery of public health care services in the ACT, and provide advice on: i. best practice responses to such complaints; ii. whether referral of such complaints should be made to any other authority; and iii. what support services should be provided to complainants. 
c) Examine and report on the existing workforce policies and complaints management practices to ensure their relevance and appropriateness in achieving satisfactory outcomes for all parties. 
d) Provide findings and recommendations for: i. further improving workforce culture across the ACT public health system; and ii. additional support systems required for staff and management engaged in the delivery of public health services in the ACT, including processes, training and professional development.
The Review specifically excluded investigation of individual allegations of inappropriate workplace behaviour and bullying and harassment. Where clusters of complaints were received, the senior executive of the relevant arm of the ACT Public Health System was advised. Similarly, where the Reviewers were particularly concerned during interviews about the wellbeing of an individual, with the agreement of that individual, again, a senior executive was notified. Despite the scepticism expressed by some that this Review would achieve any more than previous attempts to improve the workplace culture, the overwhelming response to the call for submissions revealed a deep desire from staff and the community for change. ... 
The Reviewers complemented these sources of information with numerous individual interviews and forums with a broad spectrum of groups including medical practitioners, nurses, allied health workers, support and administrative staff, NGOs, consumers, executives and unions. These conversations enabled the Reviewers to test findings about the problems and issues, discuss areas of best practice and identify practical solutions. Prior to presenting the results, the Reviewers wish to emphasise the positive and professional approaches they witnessed in many areas of the ACT Public Health System and the dedication of both individuals and groups in the delivery of quality care. The Reviewers have been cautious to ensure these positive aspects are not lost within the report and instead, present opportunities to build the culture by leveraging off existing strengths. It should also be emphasised that the ACT Public Health System is not alone in health sector workplace culture issues of inappropriate behaviours, bullying, discrimination and harassment. All other States and Territory health services have identified similar issues in their workplace, as have studies in international health services. 
Turning to the findings, the submissions overwhelmingly highlighted:
  • inappropriate behaviours and bullying and harassment in the workplace 
  • inefficient procedures and processes including complaints handling 
  • inadequate training in dealing with inappropriate workplace practices 
  • inability to make timely decisions 
  • poor leadership and management at many levels throughout the ACT Public Health System, and 
  • inefficient and inappropriate Human Resource (HR) practices, including recruitment.
The results from the survey similarly pointed to a number of concerning trends with 60% of respondents having witnessed bullying over the past twelve months and 35% having experienced bullying themselves. Most of the bullying was staff-on-staff. Of great concern was that 12% of staff indicated they had been subjected to physical harm, sexual harassment or abuse at work. Of these staff, 46% indicated it was by someone they worked with and 37% was by a member of the public. Almost three in four who experienced bullying or were subjected to harm did not submit a formal complaint, and worryingly, only 22% of staff had confidence in the way grievances were resolved once they were identified and reported. 
The survey results were similar across all three arms of the ACT Public Health System (ie. Canberra Health Services, Calvary Public Hospital and the Health Directorate) and were worse than comparable data for NSW Health. 
The information gathered from submissions, individual and group interviews and the staff survey reveal a worrying and pervasive poor culture across the ACT Public Health System. There are pockets of high performance where staff are proud of the quality of their work and were keen to demonstrate it to the Reviewers. By contrast, there were areas where a very poor culture had persisted over many years, and where bullying and other poor performance had not been addressed. 
Pride in working for the ACT Public Health System is low, bullying is common and confidence in how the system resolves grievances is extremely low. These issues have been identified in previous reviews(3) and audits. A point regularly raised in submissions was that whilst the contribution of poor leadership over the past few years has led to this unhealthy workplace culture, it was also generally acknowledged that this poor culture had been present for many years. 
Cautious optimism was expressed by many regarding the new leadership in the Health Directorate, Canberra Health Services and Calvary Public Hospital. However, it was acknowledged by all that establishing a great health service was a long-term proposition. The Reviewers believe the starting point for the ambition to create a happier and healthier health service requires a concerted effort by all parties and partners to ensure the vision and values of the ACT Public Health System are lived values, embraced throughout the system, integrated with strategy and constantly reflected in leadership. 
There is little doubt the vast majority of staff provide high quality health care and strive for excellence. Less embedded are the values of collaboration, integrity and respect. A program based on the Vanderbilt University Medical Center (United States) is proposed for adoption as a matter of priority throughout Calvary Public Hospital, Canberra Health Services and the Health Directorate. The program is designed to build a culture of safety and quality in the workplace by training and thus empowering staff to better support each other and raise concerns early. All evaluations of that program demonstrate its effectiveness. Programs adopting Vanderbilt principles are being implemented at present in an expanding number of health service organisations across Australia. These include the St Vincent’s Health Australia Ethos Program, and the Cognitive Institute Speaking Up for Safety and Promoting Professional Accountability programs. 
The Reviewers believe implementation of such a program would greatly benefit the ACT Public Health System in addressing issues related to poor behaviour, bullying and harassment. Developing, valuing and sustaining strong partnerships and relationships is an important mechanism to strengthen the culture within the ACT Public Health System. Internally, strengthened relationships are needed between Clinical Divisions in Canberra Health Services, between the acute and community health sectors, and between Canberra Health Services and Calvary Public Hospital. 
Externally, improved relationships with NGOs, universities, and other health sectors such as NSW Health are needed. Such improved relationships will not only contribute to improved coordinated care and enable a better research and learning system but, importantly, will help strengthen culture by breaking down the relative isolation of the ACT Public Health System. Commendable work is progressing in some of these areas with internal and external relationship building underway. Examples externally include the recent research summit with the university sector and, internally, the realignment and improved cohesiveness of the clinical divisional structures in Canberra Health Services. 
A necessary prerequisite to good clinical governance in any health system is clinical engagement. A number of very dedicated clinicians, including medical clinicians have fully engaged with this Review, even though some expressed reservations regarding the Review’s impact. However, it was apparent that, unlike nurses and allied health workers, the significant majority of the medical workforce did not engage. This was indicative to the Reviewers that such disengagement was symptomatic of their general disengagement from the management of ACT public hospitals and health services. 
Clinicians who are disengaged usually continue to provide high quality care to their individual patients which is why the hospitals in the ACT still achieve good clinical outcomes. However, such disengagement means that the health system does not benefit from the knowledge and input of individual clinicians who provide little consistent input to opportunities to improve the quality of care across the system. In such a disengaged system, clinicians continue to carry out their duties, putting their patients first, as is appropriate. Despite the positive feedback they receive from their patients and recognising at an individual patient level the outcomes they achieve, disengaged clinicians are often cynical, distrustful of the system, lack pride in their organisation, and are unhappy in the workplace. 
A critical success factor to improving the ACT Public Health System workplace culture is to enhance clinical, in particular medical, engagement within the health system. The onus to engage should be equally recognised by both individual clinicians and the system in which they work. Enhanced clinical engagement contributing to improved clinical governance is proposed. It is also proposed that, in line with many other health services across Australia, the divisional structure in Canberra Health Services should progressively adopt Clinical Divisional Directors with Business Manager support. Submissions from both individuals and organisations to the Review highlighted the inadequacy of the HR practices across all levels of the ACT Public Health System, particularly around HR systems and the local implementation of policies and procedures.  
Consistently raised themes include, inappropriate recruitment practices, lack of “customer” focus by HR staff, opaque, often heavy-handed processes of complaints handling, a perception of insufficient and uncoordinated training programs and general inefficiencies and duplication of HR processes and practices. A number of recommendations follow, which address these issues. At the time of preparing this Interim Report, a number of initiatives were underway designed to improve staff welfare. For example, the Ministers for Health and Wellbeing and Mental Health in mid-December 2018 announced the Nurses and Midwives: Towards a Safer Culture – the First Step – Strategy,  to support the fundamental rights of nurses and midwives to be safe and protected in the workplace. Similarly, the new CEO of Canberra Health Services advised the Reviewers of strategies she is implementing in such areas as: • reducing occupational violence • establishing an employee advocate role, and • facilitating targeted workshops for teams and departments with recognised disharmony and poor culture. 
All these initiatives are strongly supported by the Reviewers. However, it needs to be emphasised that the level of dissatisfaction and distrust is high and effecting the necessary improvements will be a long process that will require sustained attention. The Reviewers acknowledge the challenges in resetting the culture of a complex, multifaceted system like the ACT. Writing this report is the easy phase. For this Review to fully realise its intent and deliver the desired outcomes there will need to be a focus on developing a sustained, transparent and measurable approach for monitoring implementation. 
An Implementation Committee is proposed, chaired by the Minister for Health and Wellbeing including as members; the Minister for Mental Health, the Director-General (ACT Health), the CEO (Canberra Health Services), the General Manager (Calvary Public Hospital), Health Care Consumers Association of the ACT, relevant unions, Australian Medical Association (AMA), Australian Nursing and Midwifery Foundation (ANMF) and relevant Colleges. The Implementation Committee should auspice an independent annual external review, with similar methodology to this Review, which measures the extent of success of the implementation of the recommendations and the consequent impact on cultural change within the ACT Public Health System.
Recommendations are as follows
Recommendation 1: That the three arms of the ACT Public Health System should commence a comprehensive process to re-engage with staff in ensuring the vision and values are lived, embraced at all levels, integrated with strategy and constantly reflected in leadership. To achieve this the Health Directorate should take the lead in providing the necessary tools and guidelines and coordinate the implementation by Canberra Health Services, Calvary Public Hospital and the Health Directorate. 
Recommendation 2: That the Health Directorate, in conjunction with Canberra Health Service and Calvary Public Hospital develop an appropriate suite of measures that: • reflect on elements of a great health service - both culture and strategy • monitor patient/client perspectives of outcomes/experience • engage clinicians in their development, and • measure and monitor progress in clinical engagement. 
Recommendation 3: That a program designed to promote a healthier culture to reduce inappropriate workplace behaviour and bullying and harassment be implemented across the ACT Public Health System. The model adopted should be based on the Vanderbilt University Medical Centre’s Patient Advocacy Reporting System (PARS) and Co-worker Observation Reporting System (CORS). 
Recommendation 4: The Health Directorate convene a summit of senior clinicians and administrators at both Canberra Health Services and Calvary Public Hospital to map a plan of improved clinical services coordination and collaboration. 
Recommendation 5: The CEO of Canberra Health Services should review mechanisms to better integrate clinical streams of the community health services within the Clinical Divisional Structures. 
Recommendation 6: That the Health Directorate re-establish open lines of communication with the NGO sector and other external stakeholders. 
Recommendation 7: The initiatives already underway to develop a valued and more coordinated research strategy in partnership with the academic sector and others is strongly supported. This provides a mechanism to address culture, encourage professional development, education, training, research and other strategic issues. 
Recommendation 8: That discussions occur between ACT and NSW with a view to developing a Memorandum of Understanding (MoU) for improved collaboration between the two health services for joint Ministerial consideration. 
Recommendation 9: Clinical engagement throughout the ACT Public Health System, particularly by the medical profession, needs to be significantly improved. Agreed measures of monitoring such improvement needs to be developed through consensus by both clinicians and executives. Such measures should include participation in safety, quality and improvement meetings, reviews and other initiatives. 
Recommendation 10: There should be a clear requirement for senior clinicians to collaboratively participate in clinical governance activities. 
Recommendation 11: Canberra Health Services and Calvary Public Hospital should assess the appropriateness of the Choosing Wisely initiative as a mechanism for improving safety and quality of care, developing improved clinical engagement and greater involvement in clinical governance. 
Recommendation 12: That Canberra Health Services adopt the progressive evolution of clinically qualified Divisional Directors across each clinical Division with Business Manager support and earned autonomy in financial and personnel management. 
Recommendation 13: That an executive leadership and mentoring program be introduced across the ACT Public Health System specifically designed to develop current and future Clinical Directors and executive leaders. This program should include both current and emerging leaders. 
Recommendation 14: The three arms of the ACT Public Health System should review their HR staffing numbers and functions in light of the concerns staff have expressed regarding timeliness and confidence in current HR procedures, and the future needs for HR, as proposed in this Review. 
Recommendation 15: The recruitment processes in the ACT Public Health System should follow principles outlined in the Enterprise Agreements, Public Sector Management Act 1994 and relevant standards and procedures. 
Recommendation 16: The range of training programs for staff offered by the ACT Public Health System should be reviewed with respect to their purpose, target audience, curriculum, training styles and outcomes so that they address the issues raised in this Review. 
Recommendation 17: Should the recommendations of this Review be accepted, a public commitment should be jointly made by the Ministers for Health and Wellbeing, and Mental Health, the Director-General (ACT Health), the CEO (Canberra Health Services), the General Manager (Calvary Public Hospital), Senior Executives across ACT Public Health System and key representative organisations to collectively implement the recommendations of this Review to ensure ongoing cultural improvement across the ACT Public Health System. 
Recommendation 18: A ‘Cultural Review Oversight Committee’ should be established to oversight the implementation of the Review’s recommendations. The Committee should be chaired by the Minister for Health and Wellbeing, and include the Minister for Mental Health, the Director-General (ACT Health), the CEO (Canberra Health Services), the General Manager (Calvary Public Hospital), Senior Executives across ACT Public Health System, the Health Care Consumers Association of the ACT, relevant unions, AMA, ANMF and relevant Colleges. 
Recommendation 19: That the ‘Cultural Review Oversight Committee’ auspice for the next three years, an annual, independent and external review of the extent of implementation of the recommendations of the Review and consequent impact on cultural changes within the ACT Public Health System. 
Recommendation 20: As a result of this Review, the ‘Cultural Review Oversight Committee’ should prioritise the development of a change management and communications strategy, which clearly articulates to staff, patients/clients and the community the nature of the issues to be addressed and the mechanisms for doing it.