Valuing frontline clinician voice in healthcare governance ... · i. This critique of governance...

ISBN-13 978-0-6483077-5-4 (pdf)

copy2018 Committix Pty Ltd

Email marklockcommittixcom brvbarWebsite httpscommittixcom

This copyright work is licensed under a Creative Commons Attribution 40 International (CC BY 40) licence You may share (copy and redistribute the material in any medium or format) adapt (remix transform and build upon the material) for any purpose even com-mercially For attribution you must give appropriate credit provide a link to the license and indicate if changes were made To view a copy of this licence visit httpscreativecom-monsorglicensesby40

Citation Lock MJ (2019) Valuing Frontline Clinician Voice in Healthcare Governance A critique of governance and policy documents that frame clinician engagement in the New South Wales healthcare system Report to the Clinical Governance Unit Mid North Coast

Local Health District Committix Pty Ltd Newcastle Available httpscommittixcompro-

jectsvoice-of-the-clinician Edited and proofread by Claire Bradshaw httpwwwclairebradshawcomau Committix Pty Ltd respects Australiarsquos First Peoples as the traditional owners of Australia

Valuing frontline clinician voice in healthcare governance A critique of governance and policy documents that frame clinician engagement in the New South Wales healthcare sys-tem

Dr Mark J Lock BSc (Hons) MPH PhD

Dr MJ Lock Valuing Frontline Clinician Voice

Contents Executive Summary iii

Introduction 1

The Mid North Coast Region 6

Agency Employee Engagement Frontline Clinician Voice 8

Voiceless communication 8

No essence of frontline clinician voice in surveys 10

An enabling governance environment 11

Governance benefits only the organisation 13

Loud profession voice 15

Summary 16

Modality Governance Committee 17

Definitions as frames of reference 18

Inadequate performance measurement 19

Invisible internal organisational architecture 22

Committees as enduring governance structures 23

Summary 25

Structure Acts System 25

Institutional reforms ignore clinicians 25

Muddled governance architecture 27

Frontline clinicians ruled out of corporate governance definitions 28

Clinicians = medical doctors (and others) 29

Disempowering definitions 30

Grown in bullying soil 32

Summary 32

Discussion 33

References 35

Appendix 1 44


Executive Summary

i This critique of governance and policy documents focusses on the concept of frontline clinician voice within the broader topic of clinician engagement in a statutory govern-ment health agency in rural Australia It was conducted in 2017 as commissioned re-search to investigate how corporate governance documents shape the context for front-line clinician engagement In that context frontline clinicians are defined as the 14 reg-ulated health professionals who work day-to-day with patients

ii The critique was commissioned because frontline clinicians reported that their clinical issues were not being listened to by decision-makers in the organisation that there was a lack of feedback about issues from management that they were not being included in decision-making about issues and that they repeatedly needed to ask about unresolved issues previously raised to management

iii The critique is one part of a broader scope of work that included surveys interviews and social network analysis A journal article on the social network mapping of commit-tees was published as Lock MJ Stephenson AL Branford J Roche J Edwards MS and Ryan K (2017) Voice of the Clinician the case of an Australian health sys-tem Journal of health organization and management 31(6) 665-678

iv Keywords clinical issues frontline clinicians voice clinician engagement governance structuration theory

v The proposed high-level problem definition is that frontline clinician voice is structured out of formal decision-making processes through oversights in healthcare governance design Therefore how can frontline clinician voice be genuinely involved in organisa-tional decision-making processes

vi The critiquersquos design method and analysis are based on Anthony Giddensrsquos Structu-ration theory (AGST) which is defined as lsquothe structuration of social relationships through time and space in virtue of the duality of structurersquo1 This is reinterpreted as the structuring of frontline clinician engagement through internal organisational archi-tecture (space) and governance (time) in virtue of the duality between frontline clinicians and the health institution (Introduction)

vii Methodologically the interrelated concepts of AGST are used to interrogate govern-ance and policy documents (the lsquodatarsquo for the critique) through the conceptual schema of institution system organisation committee voice (the ISOCV schema) where the colon () represents complex transformations in and between those concepts The aim is to lsquoseersquo how frontline clinician voice is enabled and constrained in travelling to and from the floor (frontline clinicians) to the ceiling (Board and Executives) of the organisation

viiiThis critique makes three recommendations using a lsquocoinrsquo analogy

1) Empower frontline clinician voice On the agency side of the coin the nuances of frontline clinician voices are missing from NSW Ministry of Health (NSW Ministry) cli-nician engagement strategy and there is no essence of frontline clinician voice in em-ployee engagement surveys (see points 31-36 below) There is latent power to capitalise on frontline clinician voice through an enabling governance environment (see points 37-47 below) and a loud profession voice (see points 58-61 below) However use of this la-tent power is constrained by safety and quality governance definitions that rule out frontline clinician engagement (see points 48-57 below)

2) Establish a clear line of sight The middle of the coin sits between the floor (frontline clinicians) and the ceiling (Board and Executives) of healthcare organisations The


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voices of frontline clinicians disappear in the complexity between the floor and the ceil-ing (see points 91-98 below) Australian clinician engagement definitions (see points 66-76 below) as frames of reference structure top-down authority over bottom-up empow-erment in organisations with invisible internal organisational architecture (see points 116-124 below) and inadequate performance measures (see points 77-90 below) for frontline clinician engagement

3) Reframe institutional reforms On the structure (rules and resources) side of the coin the past cultural context for clinician engagement stems from bullying (see points 148-152 below) There is also a muddled healthcare governance architecture that diffuses frontline clinician voice Health institutional reforms ignore frontline clinicians and they are ruled out of governance definitions (see points 109-115 below) Furthermore clini-cal engagement definitions are structured to benefit only the organisation (see points 48-57 below and points 137-147 below) and those definitions are controlled by the perspective of the medical profession that defines frontline clinicians as lsquoothersrsquo (see points 133-147 below)

ix The three recommendations are based on sixteen findings and implications abridged below

a lsquoVoiceless communicationrsquo shows that different research traditions have different takes on the notion of voice that could inform the development of frontline clinician engage-ment strategies This development could explicitly include literature about the differ-ent conceptualisations of lsquovoicersquo by including that principle in the terms of reference for researchers and consultants engaged in constructing a knowledge base that under-pins clinician engagement strategies

b lsquoNo essence of frontline clinician voice in surveysrsquo shows the limitations of surveys that measure employee engagement the surveys need to provide more information about the who what why where when and how of engagement and disengagement Employee engagement surveys need to be explicitly linked to conceptualisations of lsquovoicersquo as expressed by frontline clinicians for the generation of meaningful statistics To achieve this frontline clinicians should be involved in their process of develop-ment The information generated should be used for developing actions and should be open transparent and sharable to all stakeholders

c There is an lsquoenabling governance environmentrsquo at the lsquoin principlersquo stage because dif-ferent levels of corporate governance are aligned ndash in principle ndash to clinician engage-ment The principle of clinician engagement and its integration through different gov-ernance levels paves the way for a more explicit emphasis on frontline clinician voice

d The healthcare systemrsquos governance levels rule out feedback to frontline clinicians in favour of extracting benefit for the organisation only The assumptions behind differ-ent governance definitions should be examined and those definitions revised so that organisational activities are also directed at benefitting frontline clinicians

e There appears to be a disconnect between the architects of clinician engagement pol-icy and strategy and the health professionals they wish to engage with The 14 profes-sional associations (p35) represent different voice lsquoframesrsquo so voice diversity should be accommodated in definitions of clinician engagement

f Clinician engagement has varying definitions framed as cliniciansrsquo transfer of knowledge one-way to the organisation in an evolving environment that struggles to break out of individual-based engagement to consider networks and public participa-tion methods of engagement A revised definition of clinician engagement could be de-veloped to reflect the empowerment of frontline clinician voice


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g There are many positive signals of the value of clinician engagement emanating from governance and policy documents However its value boils down to only measuring the response rates to the NSW Public Service Commissionrsquos People Matters Em-ployee Survey which misses the complexity of frontline clinician engagement Con-sistent phrasing of the value of clinician engagement and frontline clinician voices needs to be populated consistently to different corporate governance documents Furthermore there needs to be a clear logic diagram of the links between clinician en-gagement frontline clinician voice and organisational performance so that specific and relevant indicators can be determined

h The value of frontline clinician voice is lost through the plethora of ways to engage with frontline clinicians Filtered blocked diverted or altered ndash many are the ways for the veracity of voice to be modified in complex organisations The routes of transfor-mation from the floor to the ceiling of the District could be clearly mapped so that cli-nician engagement structures (eg committees networks and fora) can be made visible in the internal organisational architecture

i There are many formal ways to engage with clinicians but there is a lack of strategy to bind them together into an overall structure that visually ties them from the floor to the ceiling of healthcare organisations An audit of all an organisationrsquos committees could be used to assess how they engage with frontline clinician voice such as through the constituent components of terms of reference

j Institutional reforms ignore the impact on frontline clinicians and clinician engage-ment reforms occur without any guiding theory of change Frontline clinician voice could be explicitly emphasised in healthcare Acts and agreements and frontline clini-cians explicitly included in reform processes

k The muddled governance architecture may destabilise frontline cliniciansrsquo trust in healthcare administration and management Healthcare organisations can make the governance architecture clearer by drawing explicit linkages between corporate gov-ernance documents and producing governance schematics as a heuristic aid in clini-cian engagement processes

l Varying definitions of corporate governance miss the significance of employee engage-ment instead focusing on the authority and control aspects of leaders and their legiti-macy in controlling the lsquoworkforcersquo for the benefit of the organisation Definitions of corporate governance could be reframed to include frontline clinicians and the organi-sational empowerment of them

m In the clinician engagement literature the representation of the diversity of the front-line clinical workforce as lsquoothersrsquo discounts the value of their perspectives for improv-ing clinician engagement Each clinical profession could be explicitly referenced in clinician engagement strategy to reflect its unique profession voice

n Australian definitions of clinician engagement are framed as a proxy for medical doc-tors who spearhead clinician engagement improvements in the health system Rewrit-ten definitions of clinician engagement should be considered to reflect an organisa-tional transfer of power to frontline clinicians such as non-medical doctor clinicians leading clinician engagement

o Different forms of domination (eg bullying) are embedded in the cultural fabric of the NSW health system These affect frontline clinician engagement and need to be ac-counted for in the development of clinical engagement strategy The NSW Ministry of Healthrsquos Just Culture program could be reviewed to assess if it has had any effect on


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changing the culture within healthcare organisations so that clinicians feel they are supported to speak up about their clinical concerns

The mechanisms and methods for addressing each of the findings will need the involve-ment of frontline clinicians from different professions ndash a multidisciplinary approach com-bined with mixed methods long-term planning collaboration and resource allocation and a commitment to making information visible and available to all stakeholders


1 copy2019 Committix Pty Ltd

Introduction

1 Although the benefits of having engaged staff are reportedly numerous2-5 poor staff en-gagement is noted as a phenomenon occurring in Western democratic nations6 This single case is a first in Australian healthcare policy literature because it interrogates the governance of clinician engagement through a theoretically developed methodology that uncovers the numerous points and pathways from the floor (frontline clinicians) to the ceiling (Board and Executives) of an organisation

2 The critique is based on the premise that lsquoto truly understand the organisation as a sys-tem of interacting identities we must understand how levels of analysis interactrsquo7 which means to see frontline clinician voice as lsquonestedrsquo where a person is embedded in a job which is nested within a department which is nested within an organisation7 This premise is represented in the schema of institution system organisation committee voice where the colon () represents complex transformations in and between those concepts (see Figure 1) This means that engagement is structured at different and in-teracting levels

Figure 1 Levels of voice integration and diffusion (copy2018 Mark J Lock)

3 An example statement indicating the ISOCV schema is in the Corporate Governance and Accountability Compendium for NSW Health (2012) wherein the role of the board is focussed on leading directing and monitoring the activities of the local health dis-trict and the Board has specific statutory functions outlined in section 28 of the Health Services Act 1997 (NSW-MoH 2012a 301) This shows the explicit link between the institution (the Act) the system (NSW Health) the organisational structure (local health districtscorporate entities in NSW) and the Boards of the fifteen LHDs (corpo-rate governance committees)

4 A key task is to determine and describe the transformations that occur between each level within a definitional framework for the ISOCV schema The term institution re-fers to societiesrsquo values and norms about health that are encoded into legislation and af-fect decisions about frontline clinician engagement The health system refers to the phys-ical components such as organisations and committees are the key formal governance



structure of any organisation ndash powerful sites where an organisationrsquos vision mission and aims are produced and reproduced8 9 When people express their voice it carries power interests agendas intent motives behaviour principles values context mecha-nisms identity feelings influence and symbolism

5 The ISOCV schema is embedded within a theoretical framework This critique uses Anthony Giddensrsquos Structuration Theory (AGST) to sensitise the methodology and analysis AGST is defined as lsquothe structuring of social relations across space and time in virtue of the duality of structurersquo1 The concept of lsquostructurersquo is straightforward because the health system undergoes reforms (ie restructure) on a regular basis10 However structure is not to be equated with anything physical ndash like the skeleton of a human or the foundations and girders of a building ndash but is more about the unwritten social val-ues and norms of society For Giddens structure is the lsquorules and resourcesrsquo of society that only exist in and through our memory traces and are brought to life through hu-man interaction1

Figure 2 Conversion of structuration theory into empirical components (copy2018 Mark J

Lock)

6 The interpretation of AGST for this critique occurs on the left-hand side of Figure 2 (above) The double-headed arrows represent the dynamic nature of transformations between the concepts of voice to engagement to agency from organisational architec-ture to governance to modality and from health system to Acts to structure The hori-zontal arrows also traverse the vertical levels (dotted lines) because Giddens is at pains to state that his schema is merely an abstract representation of the complexity of hu-man interactions

7 The theory is converted into a methodology AGST states that lsquowhat is especially use-ful for the guidance of research is the study of first the routinized intersections of prac-tices which are the ldquotransformation pointsrdquo in structural relations and second the modes in which institutionalized practices connect social with system integrationrsquo1 In other words how does the micro-level interaction between a frontline clinician and a manager connect to the health institution The two sides of the coin are frontline clini-cian voiceinstitution of health ndash the duality between the health institution and frontline clinician voice But there is a lot going on with that coin and the AGST concepts (Fig-ure 2) help to unpack the connections between the heath institution and frontline clini-cian voice

8 The critical understanding to gain from the theoretical framework is to see the concep-tual links between the domains of agency modality and structure Modality is the mid-dle of the coin with frontline clinician voice on one side (agency) and the health institu-tion on the other side (structure) Agency is the power to make a difference to listen to a patientrsquos issues and take them lsquoup the linersquo to management A key way (facility) to do



this is to speak up at a decision-making committee1 which is a normal part of the health institution (and part of Western democratic societies) But speaking up at committees is not only a factor to be held to a single committee meeting there is a larger organisa-tional architecture and environment that shapes the decision to voice a clinical issue into decision-making processes

9 Jorm (2016) proposed that lsquoclinician engagement is an issue that must be considered within a complex socio-political contextual webrsquo and that lsquoviewing health care as a complex adaptive system provides an overarching framing for considering solutionsrsquo Jorm proposes complexity theory because it focusses lsquoon the interactions between sys-tem components where systems are diverse characterised by nesting roles relation-ships strategic and operational challengesrsquo11 However Jormrsquos subsequent analysis and discussion of clinician engagement in the Victorian healthcare system did not provide any intellectual engagement with the principles and concepts of complexity theory

10 Following the work of Frohlich Corin and Potvin (2001) context is defined here as lsquocollective engagement recursively implicated in the creation and recreation of social structure through social practicesrsquo12 Social structure is rules and resources and social practices are forms of human action and interaction embedded within power relations12 The key argument of Frohlich et al is that biomedicine ndash through medical practice ndash has stripped away the social context of disease and reduced the notion of lsquolifestylersquo to a pathological condition defined by risk factors (geographical location education level income level ethnicity and housing as social determinants of health) that are blamed on individual choice and control In effect lsquobehaviours are studied independently of the so-cial context in isolation from other individuals and as practices devoid of social mean-ingrsquo12

11 Frohlich et al focussed on lsquocollective lifestylesrsquo ndash transformed in this critique as lsquocollec-tive engagementrsquo and defined as lsquothe relationship between peoplersquos social conditions and their social practicesrsquo12 Social conditions modified here are defined as lsquofactors that in-volve a clinicianrsquos relationship with other peoplersquo12 One of the factors is lsquonestingrsquo In the paper lsquoIdentity in Organizations Exploring cross-level dynamicsrsquo Ashforth Rogers and Corley (2010) propose that lsquoto truly understand the organization as a system of in-teracting identities we must understand how levels of analysis interactrsquo (citing Klein and Kozlowski [2000])7

12 Informed by the ISOCV schema and AGST the critiquersquos methodology focusses on policy literature such as corporate governance documents and policy documents sup-plemented with academic publications Policy literature is defined as the official publica-tions of a social policy sphere from Acts legislation and regulations to health system policies to organisational reports These documents are formally sanctioned markers of institutional processes and offer the analyst a glimpse albeit limited into the invisible routines of organisational governance

13 The governance architecture (Figure 3) noting MNCLHD is a picture of the complexity of the Australian healthcare system Each box represents a policy and governance point where clinician engagement is nested within complex pathways between different gov-ernance levels The governance architecture figure (Figure 3) the AGST figure (Figure 2) and the levels of voice integration and diffusion (Figure 1) are linked Theory is highly abstract (Figure 1) and needs to be translated into more meaningful terms (Fig-ure 2) and then converted into a concrete methodology (Figure 3)

1 Committee is a broad term encompassing formally constituted groups of people that are given different ti-tles ndash team meetings committees Board Council group forum etc



14 The critiquersquos structure is presented around agency modality and structure the central domains of AGST (Figure 2) which are lsquounpackedrsquo to analogous constructs in the healthcare system Thus the lsquovoicersquo side of the coin is unpacked as agency employee engagement frontline clinician voice (roughly aligned with communication power and sanction) the middle of the coin is unpacked as modality governance internal organi-sation architecture (aligned with interpretive scheme facility and norm) and the lsquoinsti-tutionrsquo side of the coin is unpacked as structure Acts health system (aligned with sig-nification domination and legitimation)

15 The critiquersquos context is the Mid North Coast Local Health District (hereafter the Dis-trict) in the Mid North Coast Region in the Australian state of New South Wales (here-after NSW) It is a sub-region of the North Coast so named due to the geographical re-lationship to Sydney the capital city of NSW



Figure 3 Policy and Governance Architecture for frontline clinician engagement (copy2018 Mark J Lock)



The Mid North Coast Region

16 The District is located on the land of the Traditional Custodians of Australiarsquos First Peoples of the Birpai Dunghutti Gumbaynggirr and Nganyaywana Nations (see Fig-ure 4 below and the following map of NSW and the Mid North Coast)

Figure 4 Aboriginal nations of New South Wales

17 The District is a legal body corporate name for a Local Hospital Network constituted for the purposes stipulated in the National Health Reform Act 201113 and as negotiated through the Council of Australian Governmentsrsquo National Health Reform Agreement 201114 The state of New South Wales enabled that agreement through the NSW Health Services Act 1997 No 15415 which provides details of the objectives functions operations and administration of Local Health Districts (refer to Figure 5 for an over-view of the NSW health system)

Figure 5 Organisation chart of NSW health system16



18 The District employs more than 3000 clinical staff in seven public hospitals ten com-munity health centres and several specific facilities including oral health clinics drug and alcohol services and sexual health services16 At February 2017 according to the Public Hospital Funding website for the period July 2017 to February 2017 the Dis-trict received AUD$288742709 total National Health Reform payments

19 The Districtrsquos geographical boundaries cover 212193 residents living in rural and coastal settings over a geographical area of 11335 square kilometres of NSW (015 of the total land area of Australia which is slightly larger than Jamaica slightly smaller than Qatar or 37 times smaller than California (423967 km2) ndash refer to Figure 6 below

Figure 6 Geographical location of the District

20 According to the Districtrsquos website the Mid North Coast Region has the following fea-tures

21 These Mid North Coast Region snapshots ndash geography staff numbers funding the health system and Australiarsquos First Peoples ndash provide a limited sense of the lsquocontextrsquo



within which frontline clinicians live and work The subsequent sections of this cri-tique interrogate the invisible conceptual fabric for frontline clinician engagement in the Mid North Coast Local Health District (hereafter the District)

Agency Employee Engagement Frontline Clinician Voice

22 This section is concerned with unpacking the AGST domain of lsquoagencyrsquo (Figure 2) to reveal the three constituent concepts of communication power and sanction How are these evident in employee engagement and then frontline clinician voice


Lock)

23 An example of transformation relations () between the levels is that frontline clinicians communicate with colleagues and patients have power to do certain things and apply sanctions to others who do not conform with normative standards However the lsquode-pendenciesrsquo are numerous because lsquoit dependsrsquo on the person situation role gender hu-man cultural differences technical language tone mood and so forth that affect the three concepts in the agency domain

24 Furthermore large health systems have thousands of employees (incorporating front-line clinicians) wanting lsquoa sayrsquo and an organised way to facilitate this is through design-ing employee engagement strategies (targeted at the agency level) These are standard-ised aspects of an organisationrsquos corporate governance (at the modality level) which is a normal aspect embedded in health Acts (at the structure level)

Voiceless communication

25 The Australian clinician engagement literature referred to in this critique does not re-fer to any notion of lsquovoicersquo as it is expressed in other bodies of research (see Barry and Wilkinson [2016]) as outlined in this section Nor is the communication of different forms of voice captured in definitions of engagement or framed into the different gov-ernance concepts and definitions How can different conceptualisations of lsquovoicersquo inform cli-nician engagement strategies

26 For example in the employment relations (ER) literature voice is lsquoa mechanism to provide collective representation of employee interestsrsquo (such as unions and profes-sional associations) and in the organisational behaviour (OB) literature voice is lsquoseen as an expression of the desire and choice of individual workers to communicate infor-mation and ideas to management for the benefit of the organizationrsquo17 Which view or combination of views of voice could inform clinician engagement



27 The following points about the nuances of the concept of voice ndash like the different notes on a piano ndash evoke different questions to inform the development of clinician engage-ment strategies The single word lsquovoicersquo produces the notes of power interests agen-das intent motives behaviour rights principles values context mechanisms identity feelings influence and symbolism17-22

bull There is power involved in engagement Does engagement policy consider positional power (from ordinary staff to manager to director to executive etc) the inherently inequitable employer-employee contract or the political power of different profes-sions

bull Lying behind voices are different interests from grievance to autonomy to self-deter-mination What interests are evident in the development of clinical engagement plans

bull There are different agendas to voicing issues from the perspective of employees to and managers to executives to directors How are diverse agendas served by clini-cian engagement strategies

bull The intent of voice ranges from being pro-social or promotive or suggestion-focussed (helping the organisation) to justice-oriented (whistleblowing complaining) to pro-hibitive or problem-focussed How do clinician engagement strategies carry different intentions

bull There are motives in raising voice or choosing silence Voice is seen in three senses as acquiescent (disengaged behaviour based on resignation) defensive (self-protective behaviour based on fear) and prosocial (other-oriented behaviour based on coopera-tion) What are the motives embedded in clinician engagement strategies

bull Voice is linked to types of behaviour ndash organisational citizenship behaviour (OCB) such as affiliative OCB (helping) and challenging OCB (prosocial voice or speaking up to managers) which challenges the status quo of an organisation What behav-iours are encouraged through clinician engagement strategies

bull Voice carries rights principles and values from good working conditions to equity to fairness to self-determination Are clinical engagement strategies aligned to demo-cratic human and workersrsquo rights

bull In terms of context voice is nested from the institutional level (eg Western Com-munist) to the organisational level to the work unit and to different industries countries and cultures Are different nesting effects of voice considered in clinical en-gagement strategies

bull Voice is expressed through different mechanisms such as grievance processes coun-cils unions professional associations and committees Do clinician engagement strategies consider the range of mechanisms available to enable clinician voice ex-pression

bull A sense of identity is included in lsquovoicersquo reflecting a clinicianrsquos unique skills personal-ity traits and professional identity Are different levels of identity considered in the process for developing clinician engagement plans

bull Voice carries feelings such as frustration futility anger and resentment Do engage-ment strategies consider the emotive aspects of voice



bull The influence of voice depends on organisational size and complexity How does the structure of an organisation affect the expression of clinician voice

bull Voice is also symbolised in text audio video and art How is the symbolic nature of voice expressed in clinician engagement

28 Barry and Wilkinson (2016) Griffith University academics in the article lsquoPro-Social or Pro-Management A Critique of the Conception of Employee Voice as a Pro-Social Be-haviour within Organizational Behaviourrsquo identify the strengths and weaknesses of dif-ferent conceptions of voice They state that there is a lack of an integrative framework for making sense of different conceptions and different traditions of research For exam-ple they suggest that the employee relations conception of voice (narrowly focussed on individual grievance) needs to encompass individual and collective relational and com-municative formal and structural aspects of voice (p 266)

29 Finding Different research traditions have different takes on the notion of lsquovoicersquo that could inform the development of frontline clinician engagement strategies Currently clinician engagement in NSW health has no explicit expression of voice in text (as a key word) in definitions of engagement in governance documents or in performance indi-cators of engagement Therefore employees are lsquovoicelessrsquo in engagement strategies

30 Implication The development of frontline clinician engagement strategies can explic-itly include literature about the different conceptualisations of lsquovoicersquo by including that principle in the terms of reference for researchers and consultants engaged in con-structing a knowledge base that underpins clinician engagement strategies

No essence of frontline clinician voice in surveys

31 The NSW Ministry of Healthrsquos YourSay Survey was distributed to staff of the NSW health system on a biannual basis beginning from 2011 with surveys in 2013 and 2015 In 2015 more than 55935 health staff completed the survey with a response rate of 4123 The NSW Ministry of Health provides reports in lsquosummaryrsquo and lsquofullrsquo formats for the overall NSW Health system and for each organisation within the publicly funded health system publicly available on a website24

32 The Employee Engagement Index responses for the District (Table 1 below) trended upward for each question across the three survey periods and this is a similar pattern to the NSW Health Overall results (63 67 68) Whether these scores are good or bad is difficult to say as there are no comparative benchmarks Jormrsquos (2016) review of the use of different clinical engagement surveys in the Victorian health system points to the lack of an agreed approach to measuring monitoring reporting and benchmarking of clinician engagement



Table 1 ndash Employee Engagement Index responses for MNCLHD

33 In 2016 the NSW Ministry of Healthrsquos YourSay Survey was replaced (without pub-lished reason) by the NSW Public Service Commissionrsquos People Matter Employee Sur-vey (hereafter PMES) which covered all public sector departments including Health The District scored 62 on employee engagement (compared to 65 for the health sec-tor noting a change in wording of questions and a reduction in the number of ques-tions from six to five)25 In the District of the 1535 survey respondents 38 of staff were neither engaged nor disengaged Jorm (2016a) noted in the review of clinician en-gagement in the Victorian health system that lsquoit is unlikely that many survey respond-ents were grassroots cliniciansrsquo11 What is the level of engagement by staff type geographic location profession or facility type (eg hospital or community health centre)

34 The eighth principle of the NSW Health Workforce Culture Framework is lsquocontinually improving resultsrsquo26 which is not the case for measuring monitoring evaluating or re-porting on clinician engagement Furthermore in a sentence about the NSW Health YourSay Survey the NSW Annual Report 2015-2016 stated that lsquoall organisations con-tinued to develop local action plans to respond to their individual survey resultsrsquo (p 39) However there is no public information available about local action plans which feeds into the low levels of confidence that cliniciansrsquo organisations will take action on the survey results (34 agreement)27 although there is a policy commitment to building a positive workplace culture28

35 Finding The positive aspect of surveys is that they provide signposts where actions need to occur However actions need to be founded on a greater understanding about the who what why where when and how of engagement and disengagement in accord-ance with governance principles of transparency openness sharing and learning When actions are grounded in that greater understanding then other types of performance indicators can be developed that provide a better sense of the complexity of engagement with frontline clinician voice

36 Implication Employee engagement surveys need to be explicitly linked to conceptuali-sations of lsquovoicersquo as expressed by frontline clinicians for the generation of meaningful statistics To achieve this frontline clinicians should be involved in their development process The information generated should be used for developing actions and should be open transparent and sharable to all stakeholders

An enabling governance environment

37 Giddens explains that lsquothe constraining aspects of power are experienced as sanctions of various kindsrsquo ranging from the actual or implied threat of force or physical violence to

2011 (59) 2013 (65) 2015 (66)

Positive Neutral Negative Positive Neutral NegativePositive Neutral Negative

Overall I am proud to be a part of this workplace 64 21 15 69 19 12 69 18 13

I would recommend my workplace as a good place to work 53 24 23 59 20 20 60 21 20

I have a strong sense of belonging to my workplace 58 22 20 62 21 17 62 21 17

Overall I am satisfied to be working here at the present time 61 18 21 65 17 17 67 17 17

Working here makes me want to do the best job I can 62 21 17 69 17 13 71 17 12

I feel motivated to contribute more than what is normally required at work 58 20 22 63 19 18 65 18 17



lsquothe mild expression of disapprovalrsquo1 This section focusses on the enabling and con-straining aspects of policy statements in governance documents (see Figure 3 above in policy and governance documents) and how they lsquoframersquo clinician engagement

38 A Service Agreement (see Figure 3) is required between the District and the Secretary of NSW Health to set out the service and performance expectations and funding between the central administration (NSW Ministry of Health) and devolved decision-making of the District29

a Consistent with the principles of the devolution of accountability and stakeholder consultation the engagement of clinicians in key decisions such as resource allo-cation and service planning is crucial to achievement of the above objectives (p6)

b The District lsquoreaffirms the NSW Health Strategic Priorities support and develop our workforcersquo with indicator 44 lsquoBuild engagement of our people and strengthen alignment to our culturersquo29

c lsquoThe Australian Safety and Quality Frameworkhellipprovides a set of guiding princi-ples that can assist DistrictsNetworks with their clinical governance obligationsrsquo in relation to for example being lsquodriven by informationrsquo29

39 The range (a-c) of statements above show that clinician engagement is legitimised in organisational decision-making as a health system priority and as part of the Austral-ian norms in safety and quality (indicating policy lsquoalignmentrsquo) In the following state-ment note the enabling language where clinicians are embedded in the decision-making processes of the District The NSW Patient Safety and Clinical Quality Program policy directive (2005 due for review in September 2019) stated that30

The concept of clinical governance integrates clinical decision-making within an organisational framework and requires clinicians and administrators to take joint responsibility for the quality of clinical care delivered by the organisation

40 Clinicians are sanctioned for their role in the quality of clinical care which is legitimised through the Districtrsquos Clinical Services Plan31 in the priority area of lsquoPeople and Cul-turersquo Furthermore the concept of integration is important Specchia et al (2010) state that lsquothe aim of Clinical Governance (CG) is to the pursuit of quality in health care through the integration of all the activities impacting on the patient into a single strat-egyrsquo32 The use of the integration concept frames an organisational environment where clinicians can potentially affect many points and pathways in a healthcare organisation

41 The National Safety and Quality Health Service Standards Version 2 (2017)33 refer-ences the National Model Clinical Governance Framework (2017) wherein it states that lsquothere is a need to work towards an integrated system of clinical governance for the whole health systemrsquo34 lsquoIntegrationrsquo is also a legitimised concept in the NSW Health system where the Corporate Governance and Accountability Compendium for NSW Health2 (2012) states that35

For clinical governance and quality assurance structures and processes to be effective it is important that they operate at all levels of the organisation and that those staff providing front line patient care are aware of and working within these structures and processes

2 The Compendium this document is ldquolivingrdquo and regularly updated Sections 1 to 5 and 7 to 11 released in May 2013 In July 2014 Section 6 released with updates to Sections 7 8 and 9 As at December 2016 Sections 1 2 4 and 5 were updated In April 2018 Section 1 was updated



42 Integration at lsquoall levelsrsquo shows that clinical governance and corporate governance are linked Braithwaite et al (2008) suggest that corporate governance is centrally focussed on the lsquoboard room and executive suite and clinical governance is associated more closely with the ward unit department health centre and clinicrsquo36 However this re-flects the absence of an understanding about how the two ndash clinical and corporate gov-ernance ndash are formally linked in decision-making processes through routinised prac-tices It may be good policy rhetoric to make the connection between clinical and corporate gov-ernance but how is this grounded in reality

43 The Corporate Governance and Accountability Compendium for NSW Health (2012) notes that local health district (system-wide) by-laws establish clinical governance bod-ies Health Care Quality Committee Medical Staff Councils Medical Staff Executive Councils Hospital Clinical Councils and Local Health District Clinical Council35 and these are duly noted in the Districtrsquos by-laws37 This is grounded in reality where the Councils are explicitly linked to the Board through the Senior Executive Team (see Figure 3 above under lsquoLHD committeesrsquo) However the Councilsrsquo members are re-stricted to senior clinicians such as managers and directors without explicit mention of frontline clinicians (see voiceless communication above)

44 Governance through committees in the District is performed for the public good The New South Wales Auditor-General has developed a governance framework for public sector organisation In the Corporate Governance-Strategic Early Warning System (2011) it is stated that38

Good governance is those high-level processes and behaviours that ensure an agency performs by achieving its intended purpose and conforms by comply-ing with all relevant laws codes and directions and meets community expecta-tions of probity accountability and transparency

45 In a sign that this version of good governance should be a normative value the NSW Ministry of Health quotes in full the above definition in the Corporate Governance and Accountability Compendium for NSW Health (2012) Therefore there is the thematic alignment of the importance of governance at the clinical corporate and public sector levels for the benefit of NSW citizens

46 Finding It is encouraging that different levels of governance are aligned to the princi-ple of clinician engagement This is referenced for clinician engagement in decision-making in integration of patient care activities and at different levels of the organisa-tion Based on this critique of documents it is an enabling governance environment for frontline clinician engagement

47 Implication The principle of clinician engagement and its integration through differ-ent governance levels paves the way for a more explicit emphasis on frontline clinician voice

Governance benefits only the organisation

48 At the same time perhaps a constraining factor for frontline clinician engagement is the confusing levels of governance (see Figure 3) from national to state to local and the dif-ferent governance assumptions embedded into those different governance levels At the Australian national level there is the Australian Safety and Quality Framework for Health Care under which falls the National Safety and Quality in Healthcare Standards (NSQHS Standards Version 1) which brings into this critique the significance of healthcare governance for safety and quality



49 For organisational governance it was given first-order priority in the NSQHS Stand-ards Version 1 Standard 1 Governance for safety and quality in health service organi-sations39 However this emphasis on organisational governance is removed from the NSQHS Standards 2 in favour of a new Clinical Governance Standard33 Nevertheless organisational governance is moved to the Glossary (p71) in NSQHS Standards 2 and to the National Model Clinical Governance Framework (p31)

50 The NSQHS Standards Version 1 explicitly reference the ASX Corporate Governance Principles and Recommendations (3rd edition 2014) as the basis of corporate gover-ance40 Both reference Justice Owenrsquos definition of corporate governance (see point 126) though the NSQHS Standards Version 1 restate the Owen definition (underlined below) within a larger explanation39

The set of relationships and responsibilities established by a health service or-ganisation between its executive workforce and stakeholders (including con-sumers) Governance incorporates the set of processes customs policy direc-tives laws and conventions affecting the way an organisation is directed ad-ministered or controlled Governance arrangements provide the structure through which the corporate objectives (social fiscal legal human resources) of the organisation are set and the means by which the objectives are to be achieved They also specify the mechanisms for monitoring performance Effec-tive governance provides a clear statement of individual accountabilities within the organisation to help in aligning the roles interests and actions of different participants in the organisation to achieve the organisationrsquos objectives

51 This statement of corporate governance contains several important concepts of work-force structure means mechanisms aligning and objectives It also draws distinctions between the executives workforce and stakeholders and the organisational objectives through governance these concepts are important because they highlight the complex-ity of the context (see above) of frontline clinician engagement Further the final sen-tence shows that lsquoeffective governancersquo is framed as a one-way street where clinicians engage only for the benefit of the organisation This one-way syntax rules out (concep-tually) gearing the governance of the organisation to consider the needs of frontline cli-nicians (although practically they can engage through the Clinical Councils etc)

52 Further reflecting the one-way engagement syntax at the NSW state level the Corpo-rate Governance and Accountability Compendium for NSW Health (2012) Standard 2 states that lsquopublic health organisations that deliver clinical services must ensure that clinical management and consultative structures within the organisation are appropri-ate to the needs of the organisation and its clientsrsquo35 Here it is implied that the lsquoneeds of the organisationrsquo are equivalent to the needs of the workforce

53 This is somewhat transformed to the organisation level of the District where the Clini-cal Engagement Framework (unpublished) states lsquoto enhance clinical and organisa-tional outcomes in order to improve the quality and safety of patient care through in-volvement of clinicians (all disciplines) in decision-makingrsquo The thrust of that state-ment is also in the one-way mode

54 Linking governance to action the NSQHS Standards Version 1 were to ensure clinical responsibilities are clearly allocated and understood where lsquoeffective forums are in place to facilitate the involvement of clinicians and other health staff in decision-making at all levels of the organisationrsquo35 However there is no published literature that assesses an lsquoeffective forumrsquo or lsquodecision-making at all levels of the organisationrsquo Furthermore in-volvement in decision-making is for the benefit of the organisation The NSQHS Stand-ards 2 contain no statement linking lsquoforumsrsquo and clinicians to lsquodecision-makingrsquo



55 The NSQHS Standards 2 (2017) have the new Standard 1 ndash governance leadership and culture (Action 11) ndash which highlights the need for an endorsed clinical governance framework ensuring that the roles and responsibilities of clinicians are clearly de-fined33 The use of lsquoendorsedrsquo signals the need to involve frontline clinicians in the de-velopment of the clinical governance framework

56 Finding Different concepts of governance are transformed through the different gov-ernment levels (national state and local) carrying the underlying assumption that em-ployee engagement benefits only the organisation Whilst there is an emphasis on workforce and clinician engagement the needs of frontline clinicians are conceptually invisible

57 Implication The assumptions behind different governance definitions should be exam-ined and those definitions revised so that organisational activities are also directed at benefitting frontline clinicians

Loud profession voice

58 The use of lsquovoicersquo conveys a multitude of dimensions from rituals of conversation to the meaning of printed words the tone pitch and mood of speaking and the nuances of body language lsquoVoicersquo is a powerful word Look at the way health professional associa-tions use the term lsquovoicersquo to signify their intention for collective influence in the health system

bull Australian College of Nursing (2017) Factsheet lsquoNurses A Voice to Leadrsquo

bull The Allied Health Professional Association of Australia lsquoto ensure that the voice of allied health professionals are heard on issues affecting healthcare in Australiarsquo (Link)

bull The Dietitians Association of Australia is the lsquoVoice of Dietitiansrsquo ndash lsquoto advocate and provide a voice for Accredited Practising Dietitians (APDs) and the dietetic profes-sionrsquo

bull The Australian Medical Associationrsquos history lsquoMore than just a union A History of the AMArsquo quotes Dr Charles Ross-Smith lsquoto have a body which could speak with one voice on matters of a national medical characterrsquo

bull The Australian Psychological Society states lsquoThe APS is Australiarsquos peak psychol-ogy body and InPsych magazine is the voice of psychologyrsquo

bull The Pharmacy Guild of Australia in the website section lsquoAbout the Guildrsquo states that lsquowhen you support The Guild you lend your voice to a powerful group of advo-cates with a single focus to maintain and promote the interests of Community Phar-macy in Australiarsquo

bull The Australian Dental Associationrsquos lsquoStrategic Planrsquo states lsquoThe ADA has a contin-ued vision to be the recognised leader and voice in oral health for the community government and mediarsquo

bull The Chiropractorsrsquo Association of Australiarsquos lsquoadvocacy strategyrsquo involves lsquobecoming a part of and a voice within the reform of the health systemrsquo

bull The Australian Physiotherapy Associationrsquos website has a category called lsquovoicersquo for the activities of position statements publications and advertising Journal of Physio-therapy news and the Physiotherapy Research Foundation



bull The Dental Hygienistsrsquo Association of Australia advocates to lsquogive dental hygiene a voice in Australiarsquo

bull The Australian Dental Prosthetists Association in the lsquoWhy Join ADPArsquo section of its website states lsquoThe ADPA provides a voice through the collective power of a strong member organisationrsquo

bull The Australian Dental and Oral Health Therapistsrsquo Associationrsquos website of the lsquoADOHTA National Prioritiesrsquo states that it will lsquostrengthen the voice and profile of dental and oral health therapy through effective advocacy and lobbying and strong alliances and representationrsquo

bull The Occupational Therapy Associationrsquos Strategic Plan (2014-2017) states as its mission lsquoTo serve promote and represent members and be the pre-eminent voice for occupational therapy and of occupational therapists in Australiarsquo

bull Optometry Australia names itself lsquothe influential voice for the optometry professionrsquo

bull The Australian Podiatry Association aims lsquoto develop and promote podiatry excel-lence A strong Association gives everyone a stronger voicersquo

bull Osteopathy Australia states that it lsquoprovides a unified voice in promoting advocating and representing osteopathic healthcarersquo

59 The power of lsquovoicersquo is invoked to stake out a unique voiceprint for each profession ndash it is coupled with terms such as lsquostrongerrsquo lsquounifiedrsquo lsquopre-eminentrsquo lsquopowerrsquo lsquoadvocacyrsquo and lsquoleadershiprsquo Furthermore the use of lsquovoicersquo rings the bell of a deeper consciousness termed by Giddens as lsquoontological securityrsquo1 or trust when you give your voice to your profession it is about authorising the professional organisation to establish a space of professional safety Why is it that professional associations encourage lsquovoicersquo whereas lsquoengage-mentrsquo is the term preferred in health governance

60 Finding There appears to be a disconnect between the architects of clinician engage-ment policy and strategy and the health professionals they wish to engage with In the Australian clinical engagement literature and government strategies health profes-sionsrsquo voices are absent The 14 professional associations represent different voice lsquoframesrsquo so voice diversity should be accommodated in definitions of clinician engage-ment

61 Implication Explicitly use the phrase lsquofrontline clinician voicersquo in clinician engagement policy and strategy include relevant health profession associations and provide sec-tions relevant to each health professionrsquos voice

Summary

In the schema of structuration theory (Figure 2) the transformation relations from agency to employee engagement to frontline clinician voice are mapped to the concepts of communication power and sanction The transformation themes are voiceless com-munication no essence of frontline clinician voice in surveys enabling governance envi-ronment governance benefitting only the organisation and loud profession voice Each numbered point in the critique represents a factor to consider in the lsquorsquo transformation between agency engagement voice The factors are by no means causal but reveal how travelling from voice to engagement to agency involves complexity and nuance



It is clear that lsquovoicersquo is invisible in lsquovoiceless communicationrsquo and engagement surveys reflect that fact for frontline clinicians At least for engagement employees have a posi-tive enabling governance environment but this is couched in terms of agency (the power to lsquodo somethingrsquo) being beneficial only for the organisation In contrast the health professionrsquos use of lsquovoicersquo signals a mode of advocating for the needs of frontline clinicians

The next section moves to consider the middle of the coin where relations transform between the level of the agent to the level of structure (ie rules and resources)

Modality Governance Committee

62 AGST hinges on the lsquoduality of structurersquo which is about the lsquotwo sides of a coinrsquo anal-ogy In a communicative act between two agents one side of the coin is the lsquoconversa-tionrsquo and on the other side is the lsquorules of languagersquo For the duality of structure during any conversation we simultaneously use institutionalised language rules and in so do-ing we reinforce what it means for our language to be lsquonormalrsquo In other words there is a dynamic relationship between clinician voice and the health institutionrsquos norms

63 For example frontline clinicians can voice their concerns to professional associations (a political lever that is sanctioned in health Acts) which transform those concerns into position statements as presented to Ministers of Health who thereby transform them into legislation that affects the entire health system Though a simple description it grounds into reality the abstract concepts of agency modality and structure (Figure 2)


Lock)

64 Because there are thousands of employees in large organisations corporate governance (the interpretive scheme) is an overarching management framework for employee en-gagement (a sub-set of which are frontline clinicians) In the documents (the facilities) that frame corporate governance committees are the formal mechanism (the norms) le-gitimised in the internal organisational architecture as the channel for decision-making from the floor (frontline) to the ceiling (Board and Executive) of the organisation

65 The concept of lsquofacilityrsquo refers to different mechanisms methods and media of communi-cation such as governance and policy documents As Giddens notes communication has evolved to be diverse from direct verbal communication reading and writing and printed text to email to social media This critique is focussed on corporate and policy documents (see Figure 3) as the primary modality that frames on one side the scope of influence of frontline clinician voice in the District and on the other side reflects health institution values and norms about employee engagement



Definitions as frames of reference

66 One way to see modality in action through governance and policy documents is to in-terrogate the definitions of clinician engagement Jorm (2016) states that clinician en-gagement lsquois often misrepresented as a quality to be sought from clinicians by manage-ment rather than a shared state to be achievedrsquo11 a position which contradicts her defi-nition of engagement

Clinician engagement is about the methods extent and effectiveness of clinician involvement in the design planning decision making and eval-uation of activities that impact the Victorian healthcare system

67 Definitions act as lsquointerpretive schemesrsquo (like the concept of governance) whereby actions are conceptually ruled in or ruled out for consideration For example the definition of health has evolved from an individual lsquoabsence of diseasersquo perspective to one that considers the social emotional and cultural wellbeing of communities41 42 There are different versions of clinician engagement definitions in use in Australia referred to throughout this critique The Districtrsquos definition of clinical engagement is that of the Medical Engagement Scale43 (Clinical Engagement Strategy V2 unpublished) but with the substitution of lsquoall health professionalsrsquo for lsquodoctorsrsquo

The active and positive contribution of all health professionals [emphasis added] within their normal working roles to maintaining and enhancing the perfor-mance of the organization which itself recognizes this commitment in support-ing and encouraging high quality care

68 The use of the medical engagement scale by the District is normative as it is also the basis of the NSW Whole of Health Program44 and from within the context of that pro-gram is when the YourSay Surveys were conducted The Whole of Health Program still framed NSW clinical engagement when the YourSay Survey was replaced with the NSW Health PMES Survey (2016) which uses the definition of employee engagement from the United Kingdom report Engaging for Success5

Employee engagement as a workplace approach designed to ensure that em-ployees are committed to their organisationrsquos goals and values motivated to contribute to organisational success and are able at the same time to enhance their own sense of well-being

69 The syntax in that definition is both giving to the organisation and feeding back to em-ployee wellbeing In contrast the Medical Engagement Scale frames engagement as one-way with the clinician giving to the organisation There are mixed messages here ndash is it medical engagement clinical engagement or employee engagement

70 Alongside the one-way syntax of clinical engagement definitions in Australia is an indi-vidual focus The individual focus of engagement is normal the Gallup Q12 shows that the vast majority of job satisfaction research occurs at the individual level as does a popular view of employee engagement where it is pegged to an individualrsquos psychologi-cal states traits and behaviours45

71 The definitions could reflect empirical research of engagement The first-of-its-kind study by Norris et al (2017) focussing on the empirical development and testing of a clinical networks engagement tool found four actions necessary for engagement in clinical networks facilitate global engagement inform (provide with information) in-volve (work together to address concerns) and empower (give final decision-making



authority)46 This work takes engagement as a function of networks and relationships rather than only the individual

72 Norris et al (2017) used the International Association of Public Participationrsquos (IAP2) Public Participation Spectrum (inform consult involve collaborate and empower) whose syntax is presented as a continuum where the intent of lsquoparticipationrsquo (a different concept to engagement) is pitched to different purposes Participation with the public could be to provide information to offer consultation and so on to empowerment Each do-main of the spectrum has different intentions and requires different strategies with var-ying methods and timeframes

73 Interestingly Jormrsquos (2016) summary of proposed actions for improving clinician en-gagement in Victoria were pitched to the IAP2 continuum (although not cited) as set the agenda inform involve and empower11 The Oxford dictionary definition of em-powerment is lsquoauthority or power given to someone to do somethingrsquo an example is lsquothe process of becoming stronger and more confident especially in controlling onersquos life and claiming onersquos rightsrsquo Why do Australian clinical engagement definitions frame out empowerment and feedback and rule out power transfer from the organisation to frontline clini-cians

74 The Engaging for Success report (2009) also known as the Macleod Report whose defi-nition of employee engagement is used in the NSW PMES survey (p3) cites four lsquobroad enablersrsquo as being critical to employee engagement leadership engaging manag-ers voice and integrity5 The domain of voice is explained as lsquoemployees feeling they are able to voice their ideas and be listened to both about how they do their job and in decision-making in their own department with joint sharing of problems and chal-lenges and a commitment to arrive at joint solutionsrsquo Note the explicit tone in the words lsquofeelingrsquo lsquovoicersquo lsquoidearsquo lsquolistenrsquo lsquojointrsquo and lsquocommitmentrsquo in contrast the Districtrsquos tone in lsquothe active and passive contribution of all health professionalsrsquo is rather techno-cratic

75 Finding Clinician engagement has varying definitions framed as cliniciansrsquo transfer of knowledge one-way to the organisation in an evolving environment that struggles to break out of individual-based engagement to consider networks and public participation methods Asking staff to identify with definitions (by alignment with the value of the organisation) that are poorly selected disempowering and confusing may be a disen-gaging experience

76 Implication A revised definition of clinician engagement could be developed to reflect the empowerment of frontline clinician voice

Inadequate performance measurement

77 Definitions frame questions like lsquoWhat is the relationship between clinician engagement and organisational performancersquo There is nothing in Australian published academic literature to answer that question For example in the District frontline clinicians report that they do not feel like they are listened to that they receive little feedback that they re-peatedly raise issues to managers and that their clinical problems are left unresolved Consequently they are disengaged from contributing to the organisation Jormrsquos (2016) review did note the lack of feedback received from management about the advice that frontline clinicians provide through organisational fora9 Detert and Edmonson (2011) state that lsquoit is the lack of timely input ndash from those who have information they believe



is worth contributing to those with the power to act ndash that especially hampers organi-zational learningrsquo47 A barrier to lsquotimely inputrsquo is the lack of a strategic framework link-ing frontline clinician engagement through governance to organisational performance

78 The academic literature focusses on the relationship between Board performance and organisation performance inclusion of medical doctors on Boards and in leadership roles and performance measures such as financial social and hospital performance (eg bed occupancy rate and market share) as well as quality of care provided (process and outcome indicators)48 49 Bismark et al (2013) is an example of an Australian study link-ing Board governance and the NSQHS Standards50 They note a limitation of the study as being a snapshot and containing descriptive self-reported measures concluding that more research is needed on the causal relationship between clinical governance and pa-tient outcomes in public health services50

79 Interestingly the NSW publication lsquoWorkplace Culture Framework - Making a posi-tive difference to workplace culture (2011)rsquo26 ndash which has not been evaluated and is a lsquoguidelinersquo but not an official NSW Health lsquopolicy directiversquo ndash is not explicitly linked to the questions of the PMES Survey and Engagement Index and is not linked to the NSQHS Standards The Workplace Culture Framework has three statements of note (emphasis added)

1 Communication cooperation and support We listen to patients the commu-nity and each other We communicate clearly and with integrity We build trust and respect by encouraging those around us to speak up and voice their ideas as well as their concerns Through open communication we foster greater confidence and cooperation We understand that when colleagues and patients feel lsquoconnectedrsquo they are empowered to make smart choices about their work-place and the health services that are right for them

2 Valuing and investing in our people Our teams are strong and successful be-cause we all contribute and always seek ways to improve We seek respect ac-countability and best effort in a workplace where outstanding performance is en-couraged and recognised

3 Caring and innovation We welcome new ideas and ways of doing things because they can make our workplace more stimulating and rewarding and provide our patients with even greater levels of care

80 For transformation from the state level to the District (see Figure 3) the Workplace Culture Framework is not explicitly referenced in the Mid North Coast Local Health District Clinical Services Plan 2013-201726 which does explicitly relate the lsquoinitiativesrsquo to the priority area of lsquoPeople and Culturersquo and notes the inclusion of those initiatives in the Mid North Coast Local Health District Workforce Plan 2013-2018 (not publicly available)

81 Then in the lsquoPeople and Culturersquo section of the Mid North Coast Local Health District Strategic Plan 2012-201651 the following objectives are mentioned to lsquopromote an en-vironment of mutual respectrsquo to lsquoincrease clinician engagementrsquo to lsquosupport the wellbe-ing of our staffrsquo and to lsquofoster a culture of research innovation and learningrsquo On the face of it all of these align with the aspirations of the Workplace Culture Framework However these are neither reaffirmed nor reflected in the Strategic Directions 2017-2021 Mid North Coast Local Health District52 which provides a broad view that lsquosup-ports the development of our workforce through learning and development with a cul-ture that supports everyone to be their bestrsquo52



82 For transformation from the District to the health system level the reference in the Districtrsquos Corporate Governance Attestation Statement (2014) to lsquoworkforce develop-mentrsquo and nothing about workplace culture signals that the Districtrsquos transparency and accountability are limited in this area5329)because the Attestation Statement lsquomust be submitted to the Ministry as a part of the annual performance review process [and] will provide confirmation that each NSW Health organisation has sound governance systems and practices and attains the minimum expected standardsrsquo35

83 Staying with the link between the District and the health system the Mid North Coast Local Health District Service Agreement 2016-201729 which sets out lsquothe service and performance expectations and fundingrsquo (an agreement between the Board the Executive and NSW Secretary of Health) lists ten strategic objectives (p6) for the District to achieve on behalf of the NSW Government While lsquoclinician engagementrsquo is not a stra-tegic objective it provides a policy principle statement that29

The engagement of clinicians in key decisions such as resource allocation and service planning is crucial to achievement of the above objectives

84 However there are no performance measures for that statement and the Service Agree-ment does not explicitly note the Workplace Culture Framework but explicitly men-tions a Workforce Plan (p14 not publicly available) Nevertheless the Service Agree-ment explicitly affirms NSW Health Strategic Priorities one of which is lsquoStrategy 1 Support and Develop our Workforcersquo (p13) through five activities Two of these are

43 Build and empower clinician leadership to deliver better value care

44 Build engagement of our people and strengthen alignment to our culture

85 The key performance indicator for lsquoPeople and Culturersquo is the lsquoengagement indexrsquo in the People Matter Survey29 as stipulated in the NSW Health 201617 Service Agreement Key Performance Indicators and Service Measures Data Dictionary where the goal is for lsquoimproved response rates and staff engagementrsquo as measured through the lsquoengage-ment indexrsquo54 The document notes that it has lsquobeen developed to support the NSW Ministry of Health and Local Health Districts in monitoring and reporting on the 201617 Service Agreementsrsquo54

86 At the health system level (see Figure 3) the Corporate Governance and Accountability Compendium for NSW Health (2012) (referred to in the MNCLHD Service Agreement) has lsquoStandard 2 Ensure clinical responsibilities are clearly allocated and understoodrsquo with a statement ndash one of eleven ndash that lsquoeffective forums are in place to facilitate the in-volvement of clinicians and other health staff in decision-making at all levels of the or-ganisationrsquo35 This is not transformed into a lsquorecommended actionrsquo in the ensuing Gov-ernance Standards Checklist (p207) and is not converted into any indicator in the Ser-vice Agreement Key Performance Indicators (see point 85)

87 At the Australian national level in the NSQHS Standards Version 1 lsquoclinician engage-mentrsquo is not mentioned though the importance of clinical governance is recognised in Standard 1 Criterion 11 (a) lsquoestablishing and maintaining a clinical governance frame-workrsquo39 and in the statement that lsquothe clinical workforce is essential to the delivery of safe and high-quality care Improvement to the system can be achieved when the clini-cal workforce actively participates in organisational processeshelliprsquo39 However there are no indicators about workplace culture or of participation in organisational processes

88 More rhetorical statements about clinician engagement come from another state-level organisation The NSW Clinical Excellence Commissionrsquos Patient Safety and Clinical Quality Program (2005) notes that lsquokey to the success of the program is the active in-



volvement of doctors nurses allied health professionals health managers and our com-munityrsquo30 This is echoed in its Standard 2 lsquoHealth services have developed and imple-mented policies and procedures to ensure patient safety and effective clinical govern-ancersquo30 which is also reflected in academic literature where lsquoachieving high levels of pa-tient satisfaction requires hospital management to be proactive in patient-centred care improvement initiatives and to engage frontline clinicians in this processrsquo55 It is clear that effective clinician engagement is a valuable performance objective for organisations to provide safe and quality healthcare to Australian citizens

89 Finding There are many positive signals of the value of clinician engagement emanat-ing from governance and policy documents However there is inconsistent phrasing used in and between them Whatever the phrasing measuring clinician engagement boils down solely to the response rates to the PMES Survey which misses the complex-ity of frontline clinician engagement and the nuance of frontline clinician voice

90 Implication Consistent phrasing of the value of clinician engagement and frontline cli-nician voices needs to be populated consistently to different corporate governance doc-uments Furthermore there needs to be a clear logic diagram of the links between clini-cian engagement frontline clinician voice and organisational performance so that spe-cific and relevant indicators can be determined

Invisible internal organisational architecture

91 The modality domain is a messy conceptual space to navigate to get frontline clinician voice from the floor to the ceiling of the District (see Figure 3) as the previous section illustrated when tracking the phrase lsquoclinician engagementrsquo through different corporate policy documents This sub-section focusses on (modality) from the view of the lsquoinstitu-tionrsquo side of the coin and how the concept of lsquointegrationrsquo reflects the dynamic nature of relational systems

92 In AGST the concept of system integration is defined as the lsquoreciprocity between ac-tors or collectivities across extended time-space outside conditions of co-presencersquo (p28 377) For this critique the lsquosystemrsquo (following Frohlich et al) is lsquocollective en-gagementrsquo lsquocollectivitiesrsquo are committees lsquoextended time-spacersquo is the routine of com-mittee meetings and lsquooutside conditions of co-presencersquo refers to the policy and govern-ance architecture (Figure 3)

93 This sub-section proposes that the lsquomiddle of the coinrsquo be visualised as the internal or-ganisational architecture within which a lsquorealrsquo engagement mechanism is committees (meetings forums or teams see also point 54) where frontline clinicians have a chance to be heard Committees as routinised norms in Western democratic societies are the real-life example of Giddensrsquos duality of structure

94 All the internal organisational committees (IOCs) in an organisation effectively consti-tuted an organisationrsquos decision-making structures In the article lsquoRethinking Govern-ance in Management Researchrsquo the authors promote the need for more research on governance and internal organisational architecture56 A proposition of this critique is that IOCs are a rule and resource structure present outside of individuals and of time and space (where and when they occur) and existing as memory traces brought into consciousness using phrases like lsquodecision-making processesrsquo

95 An IOC is a system view includes nesting is relational and embraces complexity In contrast NSW health governance and policy documents show clinician engagement as



truncated into an array of lsquosiloedrsquo activities with the underlying assumption that dis-crete activities have aggregative flow-on effects throughout an entire organisation There are many structures through which to engage clinicians from committees to net-works advisory groups to forums councils to units departments and organisations11 35 Where is a strategic framework that elucidates how the plethora of clinician engagement mecha-nisms relate to genuine involvement in decision-making processes and organisational perfor-mance

96 For example the Corporate Governance and Accountability Compendium for NSW Health (2012) lists several ways clinicians can influence the performance of local health districts and the decisions of local management through clinical directorates local health district clinical councils membership of the various networks of the Agency for Clinical Innovation stakeholder engagement programs clinical engagement and consultation frameworks and various forums (health service forums reference groups quality coun-cils etc)35 This array of mechanisms for clinician engagement sees limited translation into good scores in the YourSay and PMES surveys In fact there is no direct theoreti-cal or empirical relationship drawn between any clinician engagement structure and the PMES survey responses (see the sub-section lsquono essence of frontline clinician voice in surveysrsquo above) What is the relationship between the establishment of Clinical Governance Units and the PMES engagement questions

97 Finding The value of frontline clinician voice is lost through the plethora of ways to engage with frontline clinicians Filtered blocked diverted or altered ndash many are the ways for the veracity of voice to be modified in complex organisations Within an invis-ible internal organisational architecture frontline clinician voices may not reach deci-sion-makers with the integrity of their messages intact

98 Implication The routes of transformation from the floor to the ceiling of the District could be clearly mapped so that clinician engagement structures (eg committees net-works and fora) can be made visible in the internal organisational architecture

Committees as enduring governance structures

99 As stated above committees are one (but not the only) real-world example of the mo-dality between agency and structure and are a practical example of the concept of gov-ernance Giddens states that lsquoroutinized practices are the prime expression of the dual-ity of structure in respect of the continuity of social lifersquo1 Committees are routine prac-tices and meetings are ubiquitous events activities and practices in organisational life57

100 Committees come in the form of the Australian Parliament and the New South Wales Parliament (at the institutional level) the NSW Health System is managed through the Ministry of Health Executive Committee (at the health system level) all Local Health Districts are directed by Boards (at the organisational level) and internal organisa-tional committees carry out the functions of organisations (see Figure 1 for how the dif-ferent lsquolevelsrsquo are nested) Committees help to cut through all the concepts and jargon of governance policy because it is through committees that formal governance pro-cesses are developed authorised implemented and administered

101 A committee is defined as a formally constituted group of people with agreed Terms of Reference that are aligned to an organisational mission itself framed by a social policy system that is reflexive to a societal institution The Cambridge Handbook of Meeting Sci-ence states that lsquomeetings are the social action through which organizational members produce and reproduce the vision mission and achieve the aims of the organizationrsquo57 This recalls a comment made by Justice Owen in the HIH Insurance Company inquiry



He cautioned against the sole reliance on a lsquotick the boxrsquo approach to governance as-sessment stating that lsquothere is little point in having a corporate governance model if the directors fail to examine periodically its practical effectivenessrsquo Therefore he em-phasises lsquopracticesrsquo (emphasis added)3

Corporate governance ndash as properly understood ndash describes the framework of rules relationships systems and processes within and by which authority is ex-ercised and controlled in corporations Understood in this way the expression lsquocorporate governancersquo embraces not only the models or systems themselves but also the practices by which that exercise and control of authority is in fact effected

102 The concept of lsquopracticersquo is not stated in any of the definitions of governance used in NSW health corporate documents but routinised practices (of which committees are but one) are the material linkages (Owen uses the word lsquoeffectedrsquo) that bind together the different concepts of governance Both lsquopracticersquo and lsquoroutinersquo reflect the notion of lsquoen-duringrsquo governance where Justice Owen stated that lsquogovernance should be enduring not just something done from time to timersquo (also quoted in the Corporate Governance and Accountability Compendium for NSW Health)35 The notion of lsquoenduringrsquo means that governance should be institutionalised as a normal philosophy of an organisation How can frontline clinician voice become institutionalised through healthcare governance

103 It is difficult to examine that question because extant research focusses on the single committee solution to improve corporate governance and organisational performance Researchers examine the Boards of companies executive committees Commissions parliamentary committees and Councils50 58-63 A sole focus on executive and senior committees is a problem because that research links organisational performance to sen-ior committees without charting the invisible terrain of internal organisational architec-ture64

104 In contrast to the sheer volume of literature focussing on Board Executive and Senior committees there are just a handful of research articles that focus on other committees In the United States a hospital board audit process against relevant benchmarks and indicators is a part of an organisationrsquos continuous quality improvement process65-67 However that discounts the influence of internal organisational committees For exam-ple Al Balushi and West (2006) described the complexity of committees in an Omani hospital68

Committees are an essential adjunct to the hospitalrsquos managerial mechanism for introducing a participative style of management in the hospital and en-hancing the commitment of the staff to the hospitalrsquos goal and mission

105 Note the emphasis that Al Balushi and West place on linking corporate and clinical governance through the phrases lsquomanagerial mechanismrsquo lsquocommitment of the staffrsquo and lsquohospitalrsquos goal and missionrsquo They also identify many barriers to committee effective-ness from not performing functions according to the by-laws to the decision-making process poor agenda process poorly defined objectives conflicts of interest and the size and composition of meetings68 Unfortunately there is no follow-up research that pro-vides insights about factors of committee effectiveness frontline clinician engagement and organisational performance

3 httppandoranlagovaupan2321220030418-0000wwwhihroyalcomgovaufinalre-

portFront20Matter20critical20assessment20and20summaryhtml



106 Finding There are many formal ways to engage with clinicians but there is a lack of strategy to bind them together into an overall structure that visually ties them from the floor to the ceiling of healthcare organisations

107 Implication An audit of all an organisationrsquos committees could be used to assess how they engage with frontline clinician voice such as through the constituent components of terms of reference

Summary

In the schema of structuration theory (Figure 2) the transformation themes from mo-dality to governance to internal organisational architecture are definitions as frames of reference inadequate performance measurement invisible internal organisational archi-tecture and committees as enduring governance structures These reveal how difficult it is to see the pathways to and from the floor to the ceiling of the District

A way to conceptually follow the pathways is to unpack the modality domain as inter-pretive schemes (eg definitions of governance and clinician engagement) facilities (performance indicators and organisational architecture) and norms (enduring govern-ance structures) These constitute the modality of the duality of structure and the next section moves to considering to the level of structure (as rules and resources)

Structure Acts System

108 With structuration theory defined as the structuring of social relations across space and time in virtue of the duality of structure1 the concept of lsquostructurersquo is straightforward because the health system undergoes reforms (ie restructure) on a regular basis10 However structure is not to be equated to anything physical ndash like the skeleton of a hu-man or the foundations and girders of a building ndash but is about the unwritten social val-ues and norms of society For Giddens structure is the lsquorules and resourcesrsquo (see Figure 2) of society that only exist in and through our memory traces and are brought to life through human interaction1 When restructuring occurs health Acts (the rules) are re-vised to enable changes (resourcing) throughout the health system


Lock)

Institutional reforms ignore clinicians

109 For example in Australiarsquos past the value of racial superiority was codified into legisla-tion and legally supported racial discrimination69 Over time we realised those norms



needed to be changed so rules and resources also changed and we look back on the past with new interpretive schemas Constructs like lsquoracersquo and lsquoracismrsquo do not exist sep-arately from us as physical structures and determine our interactions but are brought into being in and through interaction and so are open to modification But changing entrenched social norms is difficult For example the Garling review70 demonstrated that an entrenched culture of bullying existed in the NSW health system despite the ex-istence of formal rules and resources devoted to anti-bullying reforms

110 The use of theory could help to explain how institutional reforms ignore frontline clini-cians Jorm (2016) briefly describes the existence of social exchange theory mentions complexity theory and describes a job demands-resources model but fails to provide a grounding theoretical framework for her work This reflects that any mention of lsquothe-oryrsquo is absent from Australian clinician engagement strategy In contrast the influential Australian publication Health Care and Public Policy An Australian Analysis has an entire chapter devoted to theoretical perspectives (economic political sociological and epide-miological) and the health system Why does NSW healthcare clinician engagement policy and strategy lack theoretical framing of engagement reforms

111 Reform processes in health systems are routine in Western democratic systems For ex-ample the Registered Nursing Accreditation Standards (2012) were restructured and provide a good summary of changes in the Australian health system (see section 14 p4) Those changes affect social relationships through space and time lsquoHowrsquo those changes affect relationships is through transformation The transformative mechanisms from the institutional level (rules and resources of health Acts) to the health system level are by no means easy to describe and disentangle (as Figure 3 shows)

112 In this critique health is the institution held up on Australian social values of equity efficiency and effectiveness71 How these are transformed into reality is complex as in-dicated by the health system arrangements in the National Health Reform Agree-ment14 National Healthcare Agreement (2017)72 and the National Health Reform Act (2011)13 and described in Australiarsquos Health 201642 In these documents (facility) which are physical indicators of the health institution the phrase lsquoclinician engagementrsquo does not appear once

113 The Organisation for Economic Cooperation and Development (OECD) notes that lsquoAustraliarsquos health system is highly fragmented making it difficult for patients to navi-gatersquo73 and Sturmberg et al (2012) said that it is lsquofragmented and silolizedrsquo in nature and lsquodriven by budgets and discrete disease-specific concernsrsquo74 However according to the OECD lsquoAustraliarsquos national system for regulating 14 health professions makes Aus-tralia a leader among OECD countriesrsquo73 The NSW health system has undergone nu-merous reform and restructure processes31 75-78 though there is no record of the effects of restructuring on frontline clinician engagement

114 Finding The impact of institutional reforms in the NSW health system is not consid-ered for frontline clinicians who are not explicitly visible in healthcare Acts or healthcare agreements Within reform processes changes are made to clinician engage-ment without any guiding theory of change

115 Implication Frontline clinician voice could be explicitly emphasised in healthcare Acts and agreements and frontline clinicians explicitly included in reform processes



Muddled governance architecture

116 Governance is about legitimising the power of leaders to effect control in their organi-sations the power of citizens to hold organisations to account and the power of gov-ernment to restructure the health system The governance architecture (Figure 3 be-low full figure in Appendix 1) is a picture of signification of the complexity of the Aus-tralian healthcare system

Figure 3 Governance architecture and framework (copy2018 Mark J Lock)

117 Restructures affect clinician engagement at the District state and national levels and so provide disruptive routine for healthcare organisations Additionally Australiarsquos Federal system the health institution health system organisations professions com-mittees and personal governance impinge on the interrelationships between the health institution health system organisations and frontline clinician voice The governance of the NSW healthcare system is outlined in this Corporate Governance Matrix pro-vided by the NSW Ministry of Health The main components are critiqued below with the intention to see the governance relationships that frame the organisation (see Fig-ure 3)

118 At the national level the Districtrsquos regulatory and legislative framework is operational-ised through the National Health Reform Act and National Health Reform Agreement with provisions documented in a lsquoService Agreementrsquo (see HSA 1997 p10)15 that speci-fies lsquothe number and broad mix of services and the level of funding to be providedrsquo29

119 At the state level the Districtrsquos main enabling legislation is the NSW Health Services Act 1997 No 154 which describes the components of the NSW public health system Through the Health Services Act the Districtrsquos Board is empowered to make by-laws for local governance and administration purposes additionally the Health Services Act enables the Health Services Regulation 2013 which is mostly about health staff and the constitution and procedures for meetings of the Districtrsquos Board and principal organisa-tional committees

120 Further at the state level is the Health Administration Act 1982 which is an Act to es-tablish the Department of Health and certain other bodies to vest certain functions in the Minister for Health etc and the Health Practitioner Regulation National Law (NSW) which establishes a range of functions for national health boards and their ac-creditation activities



121 At the local level the Districtrsquos strategic administrative and management framework is aligned with CORE (Collaboration Openness Respect and Empathy) values of NSW Health the NSW Performance Framework the NSW State Plan the NSW State Health Plan the NSW Rural Health Plan the NSW Government Election Commit-ments and other key plans and programs of the NSW Ministry of Health29

122 The Districtrsquos governance framework includes clinical governance in the NSW Patient Safety and Clinical Quality Program corporate and clinical governance in the Austral-ian National Safety and Quality Health Service Standards and the Australian Safety and Quality Framework for Health Care and corporate governance in the Corporate Gov-ernance and Accountability Compendium for NSW Health The annual Corporate Gov-ernance Attestation Statement (a report required by the NSW Ministry of Health of the District) lsquomust be submitted to the Ministry as a part of the annual performance review process [and] will provide confirmation that each NSW Health organisation has sound governance systems and practices and attains the minimum expected standardsrsquo35 Overall the governance architecture serves to diffuse power between the different com-ponents of the Australian health system

123 Finding The muddled governance architecture demonstrates the complexity of trans-forming the health institution into health services It indicates the sentiment that the health system is fragmented and combined with routine reform processes confuses citi-zens and destabilises frontline cliniciansrsquo trust in health administration and manage-ment

124 Implication Healthcare organisations can make the governance architecture clearer by drawing explicit linkages between corporate governance documents and producing governance schematics as a heuristic aid in clinician engagement processes

Frontline clinicians ruled out of corporate governance definitions

125 Furthermore the concept of health governance lsquoremains an elusive concept to define assess and operationalizersquo79 Australian versions of governance are a good example of that proposition At the institutional level it is normative for governance to be poorly defined and for definitions to exclude employee staff or clinician engagement Austral-ian versions of healthcare governance stem from corporate (private corporation) gov-ernance From the Australian National Audit Officersquos publication (1999) Corporate Gov-ernance in Commonwealth Authorities and Companies80

Broadly speaking corporate governance generally refers to the processes by which organisations are directed controlled and held to account It encom-passes authority accountability stewardship leadership direction and control exercised in the organisation

126 This definition is about top-down power and accountability to shareholders for perfor-mance relevant to a competitive market economy of supply and demand Invisible are employees and their rights and needs in the container of lsquothe organisationrsquo Further-more the transformation of lsquodefinitionsrsquo into reality is problematic as exemplified by the failure of the HIH Insurance Company in 2001 and the subsequent Royal Commis-sion report delivered in 2003 by the Honourable Justice Neville John Owen81 82 The Owen definition of corporate governance is used by the ASX Corporate Governance Council in its publication Corporate Governance Principles and Recommendations (3rd edi-tion 2014)40



The phrase lsquocorporate governancersquo describes lsquothe framework of rules relation-ships systems and processes within and by which authority is exercised and controlled within corporations It encompasses the mechanisms by which com-panies and those in control are held to accountrsquo

127 Although sharing similarities with the 1999 ANAO definition (see point 125) the ASX definition has new concepts of rules relationships systems and mechanisms whilst the concepts of stewardship and leadership are left out Like the definitions of clinician en-gagement there is no transparency about the inclusion and exclusion criteria for differ-ent concepts and there is no reference to published literature where these concepts are debated Key questions are unanswered who developed the governance and clinician engage-ment definitions what was the process and who else was involved

128 Justice Owen did note the existence of many definitions of corporate governance and given the diversity of Australian private companies and the flexibility needed by them when responding to different clients and markets he would not recommend any one def-inition Therefore the ASX lsquoPrinciples and Recommendationsrsquo for corporate govern-ance are not mandatory40 This is reflected in the corporate governance of Australian Government-funded entities where the enabling legislation ndash the Public Governance Performance and Accountability Act 2014 (PGPA Act) ndash does not define the concept of governance in its dictionary83

129 At the state level of New South Wales the NSW Health Administration Act 1982 No 13584 which is the enabling legislation for NSW Health Administration and Governance85 also has no definition of governance Nevertheless there are tech-nical elements of governance that are encoded into legislation for example struc-tures (Board etc) principles (transparency and accountability) and processes (re-porting and appointments)

130 Complicating the picture is the fact that Australia is a federation this has implications for inter-governmental relationships which are displayed in the mechanism of the Na-tional Health Reform Agreement (NHRA) What is evident is that while the term lsquogov-ernancersquo is used liberally throughout the NHRA its meaning is not concretely de-fined14 this is reflected in Australian academic literature86 and authoritative reports about reforming Australian healthcare87

131 Finding Varying definitions of governance exist at different levels and contain differ-ent elements They all miss the significance of employee engagement instead focussing on the authority and control aspects of leaders and their legitimacy in controlling the lsquoworkforcersquo for the benefit of the organisation

132 Implication Definitions of corporate governance could be reframed to include frontline clinicians and the organisational empowerment of them

Clinicians = medical doctors (and others)

133 The Australian clinician engagement literature frames lsquocliniciansrsquo as only medical doc-tors The 14 recognised professions are categorised as lsquoothersrsquo11 44 88-90 For example Dr Lee Gruner (2012) writing for The Quarterly a publication of The Royal Australa-sian College of Medical Administrators stated that88

The use of lsquoclinicianrsquo as a generic term encompasses all health professionals but we know we are talking primarily about doctors as there is no point in engag-ing all of the other clinicians if doctors are not part of the equation



134 Furthermore NSW Health engagement programs and activities are centred on the skills and capacity of the medical profession91-93 However in legislation Australiarsquos National Health Reform Act (2011 sect 5) defines a clinician as a medical practitioner nurse allied health practitioner or other health practioner13 In NSW the Health Prac-titioner Regulation National Law (NSW) explicitly recognises 14 health professional organisations for Aboriginal and Torres Strait Islander Health Chinese Medicine Chi-ropractic Dentistry Medical Medical Radiation Nursing and Midwifery Occupational Therapy Optometry Osteopathy Pharmacy Physiotherapy Podiatry and Psychology These professions are recognised in the National Registration and Accreditation Scheme and by the Australian Institute of Health and Welfarersquos (2014) workforce re-port

135 Finding The representation of the diversity of the clinical workforce as lsquoothersrsquo dis-counts the value of their perspectives for improving clinician engagement This is evi-dent where clinical engagement strategies in Australia are developed led and imple-mented by medical professionals

136 Implication Each clinical profession could be explicitly referenced in clinician engagement strategy to reflect its unique profession voice

Disempowering definitions

137 Giddens emphasises the importance of the knowledgeability we all have for lsquogetting onrsquo in social life and how we do this through interpersonal interaction or social integra-tion1 We simply do not exist in a vacuum our norms and values are generated in and through continuing social interaction94

138 The most recent (2016) Australian definition of clinician engagement is provided by Professor Christine Jorm in her report Clinician Engagement Scoping Paper (2016) of the Victorian healthcare system11 95

Clinician engagement is about the methods extent and effectiveness of clini-cian involvement in the design planning decision making and evaluation of ac-tivities that impact the Victorian healthcare system

139 Its syntactical form is one of clinicians lsquogivingrsquo to the lsquosystemrsquo and conceptually rules out any return or feedback to them It is a unitarist view where the value of employee voice goes one way to the firm in the belief that lsquowhat is good for the firm is good for the workerrsquo17 The unitarist assumption is reflected in the NSW Public Service Com-missionrsquos People Matter NSW Public Sector Employee Survey (2016) which states that lsquoengaged employees have a sense of personal attachment to their work and organisa-tion they are motivated and able to give their best to help the organisation succeedrsquo27

140 The syntactical structure of Jormrsquos definition is like another Australian choice by Bonias Leggat and Bartram (2012) where they discuss the role of the concept of clini-cal engagement and participation in Australian health system reform89

Clinical engagement is defined as the cognitive emotional and physical contri-bution of health professionals to their jobs and to improving their organisation and their health system within their working roles in their employing health service

141 The emphasis is on clinicians lsquogivingrsquo through a constrained mode of communication lsquocontributionrsquo where the transaction of power occurs in the one-way transfer (jobs to



the organisation to the system) without any return on investment to the clinician That this is an Australian norm is evident in Queensland Healthrsquos (2016) definition of96

hellipthe involvement of clinicians in the planning delivery improvement and evaluation of health services within Queensland Health utilising cliniciansrsquo clinical skills knowledge and experience

142 Again a one-way transaction syntax However the Queensland Clinical Senate (2013) stated that lsquoeffective clinician engagement should lead to improved health outcomes and efficiencies It should empower staff and increase job satisfactionrsquo100 The Queensland Clinical Senate holds a minority view because the Queensland Health definition (2016) was proposed for the Western Australian health system by Professor Quinlivan (Chair of the Western Australian Clinical Senate)

143 Professor Quinlivan (WA) is a medical doctor as is Professor Jorm who is influential in discussions about medical engagement and the Australian health system The New South Wales Whole of Health Hospital Program (2013) used the following definition of medical engagement (as does the District)44

The active and positive contribution of doctors within their normal working roles to maintaining and enhancing the performance of the organisation which itself recognises this commitment in supporting and encouraging high-quality care

144 While that definition is explicitly about medical doctors43 it is uncritically used by Dr Sally McCarthy (a medical doctor) as a proxy for clinician engagement in NSW Fur-thermore NSW has a vastly different institutional context to the United Kingdom health system (see this blog) where the Medical Engagement Scale was developed Jorm (2016) notes that in the United Kingdom all clinicians are salaried employees of the National Health Service11 Furthermore the Engaging for Success (2009) report is also from the United Kingdom and does not refer at all to medical engagement yet its definition for employee engagement is used in the PMES survey

145 In all the definitions above the syntax is for employees transferring power to the or-ganisation and never the organisation transferring power to employees It is a hierar-chical structure that assumes the organisation is the tip of an iceberg under which sits an invisible (and voiceless) workforce In a 2016 there was a NSW Health scandal with media speculation that the entire NSW hospital system was now unsafe following re-ports of incidents and ldquocover uprdquo involving medical treatment at St Vincentrsquos and Bankstown hospitals Australian Medical Association NSW president Dr Brad Frankum said lsquothere is still hierarchical structure in hospitals that mitigates people feel-ing they can speak uprsquo Barry and Wilkinson (2016) argue that the organisational be-haviour conception of voice is restricted to lsquoan activity that benefits the organization [which] leaves no room for considering voice as a means of challenging management or indeed simply as being a vehicle for employee self-determinationrsquo17 The implications are profound as downstream feedback mechanisms are ruled out through the syntax of Australian clinical engagement definitions

146 Finding Australian definitions of clinician engagement are structured for the one-way benefit of the organisation within which the phrase lsquoclinician engagementrsquo is a proxy for medical doctors who spearhead clinician engagement improvements in the health system

147 Implication Rewritten definitions of clinician engagement should be considered to re-flect an organisational transfer of power to frontline clinicians such as non-medical doctor clinicians leading clinician engagement



Grown in bullying soil

148 Other forms of domination other than medical professional dominance exist in the NSW health system A bullying culture is the soil for the growth of clinical engage-ment in New South Wales as uncovered in the 2008 Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals by Peter Garling SC (the Garling Report)97 He noted that lsquoalmost everywhere that I went I was told about incidents of bullyingrsquo despite the existence of anti-bullying policy and reporting processes

149 The Garling Report stated that there was a lsquobreakdown of good working relations be-tween clinicians and managementrsquo98 and set out an agenda for improvement through the establishment of the Agency for Clinical Innovation and Executive Clinical Director positions as well as the implementation of a lsquoJust Culturersquo program99 What effects have the Just Culture program and clinical engagement reforms had on improving clinician engage-ment

150 When frontline clinicians feel that they are not being listened to that their voices are not being heard they may be silenced by an endemic culture of bullying Skinner et al (2009) in their commentary lsquoReforming New South Wales public hospitals an assess-ment of the Garling inquiryrsquo wrote that lsquobullying should be dealt with through disper-sal of power ndash by establishing clear and transparent decision-making processes with genuine involvement of the community and cliniciansrsquo98 However according to the 2016 Inquiry into Medical Complaints Processes in Australia the culture of bullying and harassment in the medical profession is endemic Elise Buissonrsquos 2017 article lsquoWe know the way but is there the will to stop bullyingrsquo references Skinner et alrsquos solu-tion However both fail to provide any logic for that proposition and do not provide any references to how that goal should be reached

151 Finding Different forms of domination are embedded in the cultural fabric of the NSW health system These affect frontline clinician engagement and need to be accounted for in the development of clinical engagement strategies

152 Implication The Just Culture program could be reviewed to assess if it has had any ef-fect on changing the culture within healthcare organisations so that clinicians feel they are supported to speak up about their clinical concerns

Summary

In the schema of structuration theory (Figure 2) the transformation relations from structure to Acts to system are unfurled to show the concepts of signification domina-tion and legitimation The transformation themes are institutional reforms ignore cli-nicians a muddled governance architecture frontline clinicians are ruled out of govern-ance definitions clinicians are defined as only medical doctors (and others) engagement is framed by disempowering definitions and clinician engagement is grown within a bullying soil These provide a sense of an unwritten value of disrespect and disregard for frontline clinicians in the health institution



Discussion

Frontline clinicians report that their clinical issues remained unresolved because of poor de-cision-making processes and so they feel that they are not listened to by management Therefore the aim of this critique was to identify the enabling and constraining points and pathways between the floor and the ceiling in the District The critique used the concept of governance to unpack the lsquoorganisationrsquo and lay it out so there could be a clear line of sight between the floor and the ceiling Therefore the logic was clinician voice committee or-ganisation system institution although this is not a linear and one-way process but a dy-namic interrelationship But it is not enough to do the unpacking without understanding how the transformations of voice can occur through one level to another Structuration the-ory provided the sensitising concepts to understand those transformations that occur within the complexity of healthcare organisations and nuances of the concept of voice

Through structuration theory the floor to the ceiling analogy is a duality between clinician voice and the institution of health ndash or if you will a coin with one side as lsquovoicersquo and the other side as lsquoinstitutionrsquo There is a lot going on between the two sides of that coin (see Figure 3) The critique worked off the proposition that there is the structuring of frontline clinician engagement through internal organisational architecture (space) and governance (time) in virtue of the duality between frontline clinician voice and the health institution According to AGST (Figure 2) the lsquovoicersquo side of the coin became agency clinical engage-ment clinician voice (unfurled as communication power and sanction) the middle of the coin became modality corporate governance committees (unfurled as interpretive scheme facility and norm) and the lsquoinstitutionrsquo side of the coin became structure Acts health sys-tem (unfurled as signification domination and legitimation) It is now the task to combine the themes and findings of this critique into recommendations that promote the genuine en-gagement of frontline clinicians in organisational decision-making processes

The notion of lsquogenuine engagementrsquo means that there is the need to do more to promote employee engagement other than taking surveys A Gallup news article ndash lsquoThe Worldwide Employee Engagement Crisisrsquo ndash calls lsquocheck the boxrsquo surveys for measuring employee en-gagement a flawed approach to improving engagement The Gallup article goes on to pro-vide five ways4 to improve engagement none of which are evident in the District or the NSW Health System However this is a qualified assessment because a lack of information is a key finding of this review as indicated by questions there may well be many actions oc-curring through local plans that are not available in the public domain

The Thematic Framework (Figure 7 below) shows how the critiquersquos main themes are mapped to the concepts of AGST to show a whole-of-system view that the themes relate to one another and that action on multiple points and pathways is needed to improve frontline clinician engagement

4 The five ways are integrate engagement into the companyrsquos human capital strategy use a scientifically vali-

dated instrument to measure engagement understand where the company is today and where it wants to be in the future look beyond engagement as a single construct and align engagement with other workplace priorities



Figure 7 Themes mapped to structuration theory (copy2018 Mark J Lock)

The 16 themes of the critique combine to form three recommendations

1 Empower frontline clinician voice On the agency side of the coin the nuances of frontline clinician voices are missing from clinician engagement strategy and there is no essence of frontline clinician voice in surveys There is latent power to capital-ise on frontline clinician voice through an enabling governance environment and loud profession voice However use of this latent power is constrained by safety and quality governance definitions that rule out frontline clinician engagement

2 Establish a clear line of sight The distance between the floor (frontline clinicians) and the ceiling (Board and Executives) is wide and invisible The definitions as frames of reference structure authority over empowerment in an organisation with invisible internal organisational architecture and inadequate performance measure-ment for frontline clinician engagement It is possible to establish a line of sight for decision-making processes with committees viewed as enduring governance struc-tures

3 Reframe institutional reforms On the structure (as rules and resources) side of the coin clinician engagement is grown in bullying soil Additionally clinician engage-ment occurs within a muddled governance architecture In the health institution in-stitutional reforms ignore frontline clinicians and they are also ruled out of govern-ance definitions Furthermore frontline clinicians are disempowered through clinical engagement definitions that benefit only the organisation and those definitions are controlled by the perspective of medical profession that defines frontline clinicians as lsquoothersrsquo

Frontline clinicians want to have confidence that their organisation will act on survey re-sults and organisations want employees who speak up to ensure that patients receive high quality of care The mechanisms and methods for addressing each of the three review find-ings will need the involvement of frontline clinicians from different professions ndash a multidis-ciplinary approach combined with mixed methods long-term planning collaboration and resource allocation and a commitment to making information visible and available to all stakeholders



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Berkeley University of California Press Available

httpswwwucpressedubook9780520057289the-constitution-of-society Accessed 11 July

2018

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Online Harvard Business School Publishing Available

httpshbrorgresourcespdfscommachievershbr_achievers_report_sep13pdf Accessed

14 September 2017

3 Hays Australia (2016) Staff Engagement Ideas for Action Online Hays Worldwide

Available

httpswwwhayscomaucsgroupshays_commonaucontentdocumentsdigitalasset

hays_326958pdf Accessed 14 September 2017

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Corporation Software Group Available

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df Accessed 14 September 2017

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Engagement A Report to Government London Department for Business Innovation and

Skills 2009 Available httpengageforsuccessorgengaging-for-success Accessed 30 August

2017

6 Scott R (2017) Employee Engagement Is Declining Worldwide Available

httpswwwforbescomsitescauseintegration20170601employee-engagement-is-

declining-worldwide4b8bc03f34e2 Accessed 14 September

7 Ashforth BE Rogers KM Corley KG (2011) Identity in Organizations Exploring Cross-

Level Dynamics Organization Science Vol22(5)1144-1156 Available

httpsdoiorg101287orsc11000591

8 Allen JA Lehmann-Willenbrock N Rogelberg SG (2015) An Introduction to the

Cambridge Handbook of Meeting Science Why Now In Allen JA Lehmann-Willenbrock N

Rogelberg SG (Eds) The Cambridge Handbook of Meeting Science New York Cambridge

University Press

9 van Vree W (2011) Meetings The Frontline of Civilization The Sociological Review

Vol59(s1)241-262 Available httpsdoiorg1011112Fj1467-954X201101987x

10 Greenfield D Hinchcliff R Banks M Mumford V Hogden A Debono D Pawsey M

Westbrook J Braithwaite J (2014) Analysing Big Picture Policy Reform Mechanisms The

Australian Health Service Safety and Quality Accreditation Scheme Health Expectations

Vol18(1369-7625 (Electronic))3110-3122 Available

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httpswww2healthvicgovauaboutpublicationspoliciesandguidelinesclinical-

engagement-scoping-paper Accessed 16 September 2017



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Context and Disease Sociol Health Illn Vol23(6)776-797 Available

httpsonlinelibrarywileycomdoiabs1011111467-956600275

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httpswwwlegislationgovauSeriesC2011A00009 Accessed 30 October 2017

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COAG Available

httpwwwfederalfinancialrelationsgovaucontentnational_health_reformaspx Accessed

15 October 2018

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httplegislationnswgovauviewact1997154fullhttplegislationnswgovauvie

wact1997154full Accessed 6 July 2016

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Ministry of Health Available

httpwwwhealthnswgovauannualreportpagesdefaultaspx Accessed 26 June 2016

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of Employee Voice as a Pro-Social Behaviour within Organizational Behaviour British Journal

of Industrial Relations Vol54(2)261-284 Available httpdxdoiorg101111bjir12114

18 Detert JR Trevintildeo LK (2010) Speaking up to Higher-Ups How Supervisors and Skip-Level

Leaders Influence Employee Voice Organization Science Vol21(1)249-270 Available


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Leaders Understanding When Units Are Helped or Hurt by Employee Voice Administrative

Science Quarterly Vol58(4)624-668 Available

httpasqsagepubcomcontent584624fullpdf

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of Psychological Attachment and Detachment on Voice Journal of Applied Psychology

Vol93(4)912 Available

httpovidsptxovidcomovftpdfsFPDDNCGCGCHGNO00fs046ovftlivegv02500004

56500004565-200807000-00015pdf

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as Multidimensional Constructs Journal of Management Studies Vol40(6)1359-1392

22 Hengst JA Duff MC Prior PA (2008) Multiple Voices in Clinical Discourse and as Clinical

Intervention International Journal of Language amp Communication Disorders Vol43(sup1)58-68

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Available httpwwwhealthnswgovauworkforceyoursay2015Pagesdefaultaspx

Accessed 18 May 2017

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httpwwwhealthnswgovauworkforceyoursayPagesdefaultaspx Accessed 30

November



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httpwwwpscnswgovaureports---datastate-of-the-sectorpeople-matter-employee-

surveypeople-matter-employee-survey Accessed 30 November

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Difference to Workplace Culture Sydney Workforce Development and Innovation NSW

Department of Health Available httpwwwhealthnswgovauworkforcepagesworkplace-

culture-frameworkaspx Accessed 10 August 2018

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Survey Cluster Report-Health Sydney NSW Government Available


surveypeople-matter-employee-survey-2016healthhealth-reports

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Health Available httpwwwhealthnswgovauannualreportpagesdefaultaspx Accessed

22 March 2018

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Program Sydney NSW Ministry of Health Available

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Services Plan 2013-2017 Coffs Harbour MNCLHD Available

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Accessed 4 April 2018

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Implementation by Health Providers BMC Health Serv Res Vol10(1)1-15 Available

httpdxdoiorg1011861472-6963-10-174

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framework Accessed 30 November 2017

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NSW Health North Sydney NSW Ministry of Health Available

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Series No 15 Cat No Aus 199 Canberra AIHW Available

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The International Journal of Clinical Leadership Vol16(4)213-223 Available

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October 2017

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ce20Through20Implementing20Internal20Audit20Standard20211020-

20Austinpdf

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in Large Nonprofit Health Systems Current Profile and Emerging Patterns Health



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amp Process Improvement in Oman Journal of Health Sciences Management and Public Health

Vol7(1)30-41 Available httpmedportalgeemlpublichealth2006n13pdf

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Australian Constitution Adelaide Law Review Vol36(1)241-256 Available

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NSW Public Hospitals - Overview Sydney NSW Department of Premier and Cabinet

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commission-of-inquiry-into-acute-care-services-in-new-south-wales-public-hospitals

Accessed 28 February 2019

71 Australian Institute of Health and welfare (2014) Australias Health 2014 Australias Health


httpswwwaihwgovaureportsaustralias-healthaustralias-health-2014contentstable-of-

contents

72 Australian Institute of Health and Welfare (2017) National Healthcare Agreement (2017)

Canberra AIHW Available httpmeteoraihwgovaucontentindexphtmlitemId629963

73 OECD (2015) OECD Reviews of Health Care Quality Australia 2015 Raising Standards

Paris OECD Publishing Available httpwwwoecdorgaustraliaoecd-reviews-of-health-

care-quality-australia-2015-9789264233836-enhtm Accessed 15 September 2017

74 Sturmberg JP OHalloran DM Martin CM (2012) Understanding Health System

Reformndasha Complex Adaptive Systems Perspective J Eval Clin Pract Vol18(1)202-208

Available httponlinelibrarywileycomdoi101111j1365-2753201101792xabstract

75 Liang ZM Short SD Lawrence B (2005) Healthcare Reform in New South Wales 1986ndash

1999 Using the Literature to Predict the Impact on Senior Health Executives Australian

Health Review Vol29(3)285-291 Available

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76 Foley M (2011) Future Arrangements for Governance of NSW Health Sydney NSW

Ministry of Health Available httpwww0healthnswgovaugovreview Accessed 1

October 2014

77 NSW Ministry of Health (2015) What Is Health Reform Available

httpwwwhealthnswgovauhealthreformpageshealthreformaspx Accessed 15

September 2017

78 NSW Ministry of Health (2015) Governance Review Available

httpwwwhealthnswgovauhealthreformPagesgovernance-reviewaspx Accessed 15

September 2017



79 Barbazza E Tello JE (2014) A Review of Health Governance Definitions Dimensions and

Tools to Govern Health Policy Vol116(1)1-11 Available

httpsdoiorg101016jhealthpol201401007 Accessed 11 July 2018

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and Companies - Discussion Paper Barton ACT ANAO Available

httpswwwvtaviceduaudocument-managergovernancelinks121-corporate-

governance-in-commonwealth-authorities-a-companiesfile Accessed 13 September 2018

81 Allan G (2006) The HIH Collapse A Costly Catalyst for Reform Deakin Law Review

Vol11(2)137-159 Available

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82 Bailey B (2003) Research Note Report of the Royal Commission into HIH Insurance

Canberra Deparment of the Parliamentary Library Information and Research Services

Available

httpparlinfoaphgovauparlInfosearchdisplaydisplayw3pquery=Id3A22library2F

prspub2FXZ89622

83 Commonwealth of Australia (2013) Public Governance Performance and Accountability Act

2013 Available httpswwwcomlawgovauDetailsC2015C00187 Accessed 10 September

2016

84 NSW Government (2017) Health Administration Act 1982 No 135 Available

httpwwwlegislationnswgovauviewact1982135full Accessed 20 June

85 NSW Ministry of Health (2017) Health Administration and Governance Available

httpwwwhealthnswgovaulegislationPageshealth-administration-governanceaspx

Accessed 20 June

86 Veronesi G Harley K Dugdale P Short SD (2014) Governance Transparency and

Alignment in the Council of Australian Governments (COAG) 2011 National Health Reform

Agreement Australian Health Review Vol38(3)288-294 Available

httpwwwpublishcsiroauindexcfmpaper=AH13078 Accessed 23 October 2017

87 National Health and Hospitals Reform Commission (2008) Beyond the Blame Game

Accountability and Performance Benchmarks for the Next Australian Health Care Agreements

Canberra NHHRC Available httpreferencewolframcomlanguage

88 Gruner L (2012) Clinician Engagement Change the Language Change the Outcome The

Quarterly Available

httpwwwracmaeduauindexphpoption=com_contentampview=articleampid=506ampItemid=25

7

89 Bonias D Leggat SG Bartram T (2012) Encouraging Participation in Health System

Reform Is Clinical Engagement a Useful Concept for Policy and Management Australian


httpwwwpublishcsiroauindexcfmpaper=AH11095

90 Skinner J Australian Salaried Medical Officers Federatin Australian Medical Association

(2015) Joint Statement of Cooperation Online NSW Ministry of Health Available

httpwwwhealthnswgovauworkforceDocumentsAMA-ASMOF-joint-statementpdf



91 Agency for Clinical Information (2016) Outcomes from the Medical Engagement Forum

2016 Online unpublished report Available httpwwwasmofnsworgaulatest-

newsmedical-engagement-forum-outcomes

92 Dickinson H Bismark M Phelps G Loh E Morris J Thomas L (2015) Engaging

Professionals in Organisational Governance The Case of Doctors and Their Role in the

Leadership and Management of Health Services Melbourne Melbourne School of Government

Available httpbespoke-

productions3amazonawscommsogassets3ffcbbf0b84911e69954275e8ac44c66MNGMT

_Of_Health_Servicespdf

93 Dickinson H Bismark M Phelps G Loh E (2016) Future of Medical Engagement


94 Emirbayer M (1997) Manifesto for a Relational Sociology The American Journal of Sociology


httpswwwjstororgstable101086231209seq=1page_scan_tab_contents Accessed 28

February 2019

95 Jorm C (2016) Clinician Engagement Scoping Paper Executive Summary unpublished

report Available



96 Cairns and Hinterland Hospital and Health Service Clinical Council (2016) Clinician

Engagement Strategy 2016-2019 Cairns Queensland Health Available

httpswwwhealthqldgovau__dataassetspdf_file0027628416clin-coun-engagepdf

Accessed 1 May 2018

97 Garling P (2008) Final Report of the Special Commission of Inquiry Acute Care Services in

NSW Public Hospitals Sydney NSW Department of Premier and Cabinet Available

httpwwwdpcnswgovau__dataassetspdf_file000334194Overview_-

_Special_Commission_Of_Inquiry_Into_Acute_Care_Services_In_New_South_Wales_Public_

Hospitalspdf

98 Skinner CA Braithwaite J Frankum B Kerridge RK Goulston KJ (2009) Reforming

New South Wales Public Hospitals An Assessment of the Garling Inquiry Med J Aust


httpswwwmjacomausystemfilesissues190_02_190109ski11396_fmpdf Accessed 28

February 2019

99 Garling P (2008b) Final Report of the Special Commission of Inquiry Acute Care Services in

NSW Public Hospitals Volume 1 Sydney NSW Deparment of Premier and Cabinet






Appendix 1

Governance Architecture and Framework (copy2018 Mark J Lock click to go back to lsquoMuddled governance architecturersquo)


Voice of the Clinician Project Director Clinical Governance Ms Kathleen Ryan Manager Ms Jill Bran-ford Project Officer Mr Jonno Roche Consultant Dr Mark J Lock of Committix Pty Ltd The interpretations in this critique do not represent the opinion of the Mid North Coast Local Health Dis-trict


Founder and Director

Committix Pty Ltd ABN 786 146 747 34

Email marklockcommittixcom

Ph +61 (0) 416871616


Contents Executive Summary iii

Introduction 1

The Mid North Coast Region 6

Agency Employee Engagement Frontline Clinician Voice 8

Voiceless communication 8

No essence of frontline clinician voice in surveys 10

An enabling governance environment 11

Governance benefits only the organisation 13

Loud profession voice 15

Summary 16

Modality Governance Committee 17

Definitions as frames of reference 18

Inadequate performance measurement 19

Invisible internal organisational architecture 22

Committees as enduring governance structures 23

Summary 25

Structure Acts System 25

Institutional reforms ignore clinicians 25

Muddled governance architecture 27

Frontline clinicians ruled out of corporate governance definitions 28

Clinicians = medical doctors (and others) 29

Disempowering definitions 30

Grown in bullying soil 32

Summary 32

Discussion 33

References 35

Appendix 1 44


Executive Summary







































Introduction











Lock)








































Lock)







































2011 (59) 2013 (65) 2015 (66)





































































Summary










Lock)



















































































Summary






Lock)











































































Summary




Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616


Executive Summary







































Introduction











Lock)








































Lock)







































2011 (59) 2013 (65) 2015 (66)





































































Summary










Lock)



















































































Summary






Lock)











































































Summary




Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616





























Introduction











Lock)








































Lock)







































2011 (59) 2013 (65) 2015 (66)





































































Summary










Lock)



















































































Summary






Lock)











































































Summary




Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616






Lock)








































Lock)







































2011 (59) 2013 (65) 2015 (66)





































































Summary










Lock)



















































































Summary






Lock)











































































Summary




Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616





































Lock)







































2011 (59) 2013 (65) 2015 (66)





































































Summary










Lock)



















































































Summary






Lock)











































































Summary




Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616


































2011 (59) 2013 (65) 2015 (66)





































































Summary










Lock)



















































































Summary






Lock)











































































Summary




Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616






























































Summary










Lock)



















































































Summary






Lock)











































































Summary




Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616









Lock)



















































































Summary






Lock)











































































Summary




Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616

















































































Summary






Lock)











































































Summary




Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616









































































Summary




Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616



Discussion

















References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616











References




2018




14 September 2017


Available










2017










University Press



















COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616









COAG Available


15 October 2018





















56500004565-200807000-00015pdf










November
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616
















22 March 2018








September 2017








httpdxdoiorg1011861472-6963-10-174

















































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616






































































April 2018




July 2017






October 2017











scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616






scienceBF8D238A6062347DC177731365760380




20160529






























20Austinpdf





















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616



















contents















October 2014



September 2017



September 2017















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616















Available


prspub2FXZ89622



2016





Accessed 20 June









Quarterly Available


7
























February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616

















February 2019


report Available






Accessed 1 May 2018





Hospitalspdf





February 2019








Appendix 1








Ph +61 (0) 416871616



Appendix 1








Ph +61 (0) 416871616







Ph +61 (0) 416871616

Valuing frontline clinician voice in healthcare governance ... · i. This critique of governance...

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