Health professional perceptions of clinical …...1 Health professional perceptions of clinical...

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HealthprofessionalperceptionsofclinicalgovernanceandthequalityandsafetyenvironmentinNewZealandDHBs:

Reportonthe2017nationalsurvey

ReporttoHQSC.April,2018.

ProfessorRobinGauld,Pro-Vice-ChancellorandDean,OtagoBusinessSchool,UniversityofOtago

DrSimonHorsburgh,SeniorLecturerinEpidemiology,DepartmentofPreventiveandSocialMedicine,UniversityofOtago

(AuthorsbothaffiliatedwiththeCentreforHealthSystemsandTechnology,UniversityofOtago)

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OverviewTheworkdetailedinthisreportwascommissionedbytheHealthQualityandSafetyCommission(HQSC).Itfollowsonfromearlierworkonclinicalgovernanceconductedbytheauthors,in2010and2012,someofwhichwascommissionedbygovernmentagencies.This2017studydeploysthesamesurveymethodastheearlierstudies,includinganumberofthesamequestionsaskedpreviously.Itdiffersinthatsomequestionsfromthe2012studyhavebeenreplacedbynewquestionsofinteresttoHQSCandtheNewZealandhealthsector.Keyfindingsarethatprogressonquestionsaskedin2010and2012hasbeenlimited;inmanycases,respondentsarelesspositivethantheywerein2012.Thismaybeduetoastrongerfocusin2012–nationallyandacrosstheDHBsector–onclinicalgovernancedevelopment.This2017studyhasimplicationsforhealthsectorpolicy,governanceandmanagementaswellasforhealthprofessionals.Inparticular,theremaybeaneedtorefreshtheemphasisonclinicalgovernanceandaspectsofthequalityandsafetyenvironmentnationallyandwithinDHBs.BackgroundClinicalgovernancehasbeenanimportantfoundationforhealthsystemsinarangeofcountriessincearoundthemid-1990swhenthetermwasfirstusedintheEnglishNHS.1Theconceptencapsulatesanapproachtohealthsectorandservicegovernancethatisclinically-led.Theterms‘clinicalgovernance’,clinicalleadership’and‘clinicalengagement’areoftenusedintandem,soitisusefultobrieflydefinethese.Inadaptinganearlierdefinition,1NewZealand’sInGoodHandsreport(furtherdescribedbelow)definedclinicalgovernanceasthesystemthroughwhichhealthanddisabilityservicesareaccountableandresponsibleforcontinuouslyimprovingthequalityoftheirservicesandsafeguardinghighstandardsofcare,therebycreatinganenvironmentinwhichclinicalexcellencewillflourish.2Thekeypointhereisthatclinicalgovernanceis‘thesystem’;‘clinicalleadership’–leadershipbyindividualhealthprofessionalsandprofessionalteams–ispivotaltobuildingthissystem.Clinicalengagementreferstotheideaofanemployeewhodoesnotseetheirroleasnarrowlyandspecificallydefined,providingtheminimumrequiredofthem,butratherassomeonewhoappreciatesandisproudoftheorganisationinwhichtheyworkandwishesittobeseenassuchbyothers.Theengagedemployeeisthenwillingtodomorethantheminimumexpectation,to‘gotheextramile’forthereputationoftheorganisation.3Followingonfromtheabove,thegoalofclinicalgovernanceistocreateasysteminwhichclinicalleadershipthrivesandissupported,wherecliniciansareallintegrallyinvolvedinworkingtogetheronimprovementactivities;and,ultimately,tocreateanenvironmentinwhichhealthprofessionalsareresponsibleforthegovernanceofservicequalityandpatientsafety,workingcontinuouslytoimprovethis.4Therearevariousrequirementsforstrongclinicalgovernancetohappenincluding:anadequatepolicyfocusandframeworkatthenationalandlocalservicedeliverylevels;supportforclinicalgovernancedevelopment,includingtrainingandworkplacesupport;andhealthprofessionalwillingnesstogetinvolvedinclinicalgovernance

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withtheoutcomeofrecognisingwherethesystemfailspatientsandprofessionalsandimprovingprocessesandservicesontheirbehalf.5NewZealand’sfocusonclinicalgovernancecommencedin2009followingthereportoftheMinisterialTaskGrouponClinicalLeadership.2Thisprofessionally-ledgroup,appointedbyandreportingtotheMinisterofHealth,producedaseriesofrecommendationsincludingthat:

• DHBsandtheirgoverningBoardscreategovernancestructuresthatensuredaneffectivepartnershipbetweenclinicalandcorporatemanagement,withqualityandsafetyatthetopofallmeetingagendas;

• EachDHBCEOshouldenablestrongclinicalleadershipanddecisionmakingthroughouttheirorganisation;

• Clinicalgovernanceshouldcovertheentirepatientjourney,withcliniciansactivelyinvolvedinalldecisionmakingprocessesandwithsharedresponsibilityandaccountabilitywithcorporatemanagementforbothclinicalandfinancialperformances;

• DecisionmakingshouldbedevolvedtotheappropriateclinicalunitorteamswithinDHBsandtheirhospitals;and

• DHBsshouldidentifyandsupportactualandpotentialclinicalleadersincludinginvestingintrainingandmentoring.

Onreceiptofthisreport,thethenMinisterofHealthstatedanexpectationthatallDHBswouldworktoimplementtheserecommendations.6In2010,theauthorspartneredwiththeAssociationofSalariedMedicalSpecialists(ASMS)inordertosurveytheirmembers–around90%ofpublichospitalspecialistsemployedbyDHBs.Theaimofthatstudywastogaugemedicalspecialists’perceptionsoftheextenttowhichtheMinister’sinstructionshadbeenacteduponbyDHBs.QuestionsdevelopedforthesurveystudyweredesignedtoassessprogressonkeyrecommendationsfromtheMinisterialWorkingParty,includingthoselistedabove.Fromtherespondentdataobtained,theauthorsdevelopedaClinicalGovernanceDevelopmentIndex(CGDI)whichgaveeachDHBascoreand,inturn,anoverallscoreforNZ.7In2012,afollow-upstudywasconducted.ThiswascommissionedbythethenNationalHealthBoard(partoftheMinistryofHealth),HQSCandDHBsandincludedallregisteredhealthprofessionalsinDHBemployment.8,9Itwasthelargest-everhealthworkforcesurveyconductedinNewZealand.TheClinicalGovernanceAssessmentProject(CGAP),asitwastitled,sawsomesmallmodificationstothequestionsaskedin2010.TheprojectalsoincludedsomenewquestionsasaresultofHQSCinvolvementinthestudy.Tworeportsandaseriesofacademicjournalarticleswerepublishedasaresult;4,8-14findingswerealsopresentedinamajornationalmeeting,withrepresentativesfromthecommissioningagencies,allDHBsandotherinterestedparties,heldinWellingtoninDecember2012.This2017studyaimedtomeasureprogresssince2012andwascommissionedbyHQSC.Again,somemodificationstothesurveyweremade.Somequestionsfrom2012wereremoved,andothersofinteresttoHQSCandthehealthsectoraddedin.ThemodificationsmeanthatitwasnotpossibletocreatetheCGDIusedin2010and2012.However,itispossibletochartprogress

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onkeyquestionsincludedinallthreesurveysandonquestionsincludedin2012and2017.This2017studyalsomeansavailabilityofbaselineinformationonthenewquestions.Thefocusonclinicalgovernanceandthequalityandsafetyenvironmentremainsasimportantasever.Indeed,thereisastrongargumentthatrobustclinicalgovernanceprovidesthe‘organisationalfuel’forsafe,effectiveandefficientcare;thatthejobofhealthprofessionaltraininginstitutions,policymakersandmanagersistofocusoncontinualdevelopmentandsupportofCG.Agrowingevidence-basesupportsthedemandforsuchafocus.15-19Inmanyways,CGisthehealthcareversionofwhatisknownas‘operationalexcellence’.Inagenericsense,thismeansaconcertedfocusonkeyoperationalfactorsintermsofhowworkisorganised.Whenorganisationsplaceanemphasisonthesefactors,associationswithbetterproductandservicequality,reducedcostsandimprovedperformancehavebeenfound.20OtherfactorsrelatedtoCGarealsoimportantinthecontemporarycontextofhealthcarequalityandsafetyimprovement.Theseincludetheneedforhealthprofessionalemployerstoensurethatprofessionalsundergoperiodiccredentialing,andthatprofessionalsdiscussconcernsaboutcarewithpatientsandtheirfamilies.21Thisreportdetailsthefindingsfromthe2017studyand,whererelevant,comparesthesewiththefindingsfromtheearlierstudies.Thereportisstructuredasfollows.Next,themethodsaredescribed.Thefindingsarethenpresented.Finally,thefindingsarediscussedinthecontextofthebroaderliteratureandthe2010and2012studies,alongwithsomebriefrecommendations.MethodsDHBshavebeenvariouslyinvestinginqualityimprovementactivities,oftenwithsupportofHQSCandtheMinistryofHealth.Somehavepreviouslysoughttoevaluatetheir‘safetyclimate’,22,23yetstudyfindingsarelargelynotpubliclyreported.TheCGAPstudywasthefirsttoinvestigatehealthprofessionals’perceptionsofelementsofqualityandsafetyinvolvingallDHBsandtopublicly-reportfindings.Thedevelopmentofthesurveytoolusedinthe2012CGAPstudyisdescribedinmoredetailelsewhere.8This2012toolwaslargelyreplicatedforthis2017study.Inshort,the2012toolinvolvedlimitedadaptationstoquestionsdevelopedfortheearlier2010ASMSstudy.Questionsforthis2017studyinvolvedsomefurtherminoradaptations.Somequestionsfrom2012wereremoved,andsomenewquestionsadded.ThenewquestionsweredevelopedtoassessareasofinteresttoHQSC,namelyaroundsharingpatientoutcomedata(twonewquestions)andonDHBsdefininghealthprofessionalrolesinpatientsafety(onenewquestion).Asnoted,theremovalof2012questionsmeansitwasnotfeasibletocreateaClinicalGovernanceDevelopmentIndex(CGDI)scoreforthesectororforindividualDHBsfor2017.However,thisreportdoesprovidecomparisonsofperformanceovertimewherethesamequestionshavebeenincludedinboth2012and2017.Allquestionsinthesurveyhaveundergoneconsiderablereviewandvalidationasdescribedinthe2012reportandthevariouspeer-reviewedjournalarticlesthatstemmedfromthatproject.

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Thenew2017questionswereincludedtoassessparticularareasofemphasisinHQSC’s2017advisorydocumentonclinicalgovernance.Inbrief,adetailedreviewofinternationalliteraturewasundertaken.Norelevantpre-existingquestionswerefound,sothethreenewquestionsweredeveloped.Inaniterativeprocess,theseweresubjecttoreviewbyHQSCstaff,discussedwiththeOtagoresearchteamandamendedfollowingfeedback.Thequestions,therefore,meetthebasicstandardofcontentvalidity.Severalstepsandprocesseswereinvolvedinconductingthe2017survey,withallcommunicationsasstandardaspossibleacrossthe20participatingDHBs.Theprocesswasexactlythesameasin2012,asfollows:

1. TheDHBCEOseachagreedtogenerateaninternalemaillistofallregisteredhealthprofessionalsintheiremploymenttobeinvitedtoparticipateinthesurvey.Itwasagreedthatthiswouldbemorestraightforwardthanrandomsamplingand,forseveralsmallerDHBs,staffnumbersinsomeprofessionalcategoriesweretoosmalltowarrantrandomselection;

2. EachDHBprovidedthetotalnumberofinviteesineachprofessionalcategorytotheOtagoresearchersinthefollowingformattoenablecalculationofresponserates(illustrativeexample):

ProfessionalCategory AlliedCount 76JuniorDoctorCount 12MedicalCount 30NursingCount 241

3. Atotalof53,105healthprofessionalswereinvitedtoparticipateacrossthe20DHBs;4. FromJuly-October2017,withvaryingcommencementdates,theDHBseachsentan

emailinvitetotheirprofessionalstafflistcontainingalinktothesurveywebsite.ThestafflistgenerationandemailinviteswerelargelymanagedbytheHRdepartmentineachDHB,indirectliaisonwiththeOtagoresearchers;

5. ThreefollowupemailsweresentbytheDHBstotheirstaffatweeklyintervalsafterthelaunchdateandthesurveyclosedattheendofNovember;1

6. TheOtagoresearchersmonitoredresponseratesandprovidedweeklyfeedbacktothe

DHBs;

7. AlldataanalyseswereconductedbytheOtagoresearchers.

1OneDHBsentoutonlyoneremindertostaff.

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Reportoverview

Thefollowingsectionspresentkeyfindingsfromthe2017survey,with2012comparisonswhereappropriate.

First,respondentdemographicsandresponseratedataarepresented.

ThisisfollowedbyfindingsonindividualsurveyitemsbyDHB.Wherea2017questionwasexactlythesameasin2012,acomparativedatatableisincluded.ThesetablesshowhoweachDHB’sscorehaschangedovertime.Thetablesalsoinclude95%confidenceintervals.Theseshowthatthechangesreportedareonlystatisticallysignificantincaseswheretheconfidenceintervaldoesnotinclude0(inotherwords,thechangesarenotstatisticallydifferentfrom0whenthe95%confidenceintervalincludes0).NotethatCanterburyDHBhasbeenremovedfromcomparativetables,sinceitwasnotinvolvedinthe2012survey.Thecomparativefiguresdonotexactlymatchthosefromthe2012studyduetoslightdifferencesincalculation.Comparativedataareinsertedinthecommentaryundersometableswiththecaveatthatthewayinwhichquestionswereaskedin2012and2017differedslightly;inthesecases,thereisnocorrespondingcomparativetable.

Thethirdsectionpresentsdatabyprofessionalgroup.

Thefourthsectionpresentsasmallnumberofthelargevolumeofwrittencommentsprovidedbyparticipantsinthe2017survey.Theseareillustrativeofthegeneralsentimentsofrespondents.Adiscussionofkeyfindingsandlimitationsconcludesthereport.

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1Demographics

1.1DemographicsTable(respondentswithmissingDHBhavebeenremoved)

Thetablebelowillustrates:(a)howthemixofrespondentsdifferedacrossthe2012and2017surveys;and(b)howwellthe2017surveyrespondentsrepresentthebroaderhealthworkforceintermsofdemographicmake-up.The‘NumberofRespondents’and‘PercentageofAllSurveyRespondents’columnsfor2012and2017allowsassessmentof(a).Comparingthe‘PercentageofAllSurveyRespondents’columntothe‘PercentageofWorkforce’columnallowsassessmentof(b).Forexample,respondentsin2017fromAucklandDHBmadeup6.4%ofallsurveyrespondentsbutworkersinAucklandDHBcomposed15.6%oftheNZhealthworkforce,socomparativelyspeakingtheAucklandDHBworkforceisunder-representedinthe2017survey.2

Figuresinthe‘PercentageofWorkforce’columnweresuppliedbyTechnicalAdvisoryServicesandpertainonlytothoseemployedbyDHBsanddeliveringservicesintheDHBproviderarm.Thefigureslistedareforvariableswhichwerecomparabletothosecollectedinthesurvey.Surveyrespondentswerenotparticularlyrepresentativeofthewiderworkforce.Inparticular:

*ThereweremoreAllied/Otherinthesurveyandfewernurses;

*Thesurveyparticipantswereslightlyolder,withfewerinthe20-39agerangeandmoreinthe50-59agerange;*Thesurveyparticipantstendedtohavebeenintheworkforcelonger,withfarfewerunder5yearsandfarmoreover15years.ThismaypartlybeanartefactofhowTASrecordsexperience(whichislengthofservice,andonlyincludestheirpresentposition);and*Therewerefewerfemalesamongstthesurveyparticipants.

2Atthetimethisclinicalgovernancesurveywasconducted,AucklandDHBhadrecentlyconductedanotherstaffsurveyandwerenotconfidentinobtainingastrongstaffparticipationrate.

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2017 2012

Number of Respondents

Percentage of All Survey

RespondentsNumber in Workforce

Percentage of Workforce



RespondentsDHB Auckland 578 6.4% 8603 15.6% 1751 17.0%

Bay of Plenty 508 5.7% 3324 6.0% 469 4.6%

Canterbury 422 4.7% 6896 12.5% 0 0.0%Capital and Coast 346 3.9% 4346 7.9% 1097 10.6%

Counties Manukau 1051 11.7% 4816 8.8% 277 2.7%

Hawke's Bay 459 5.1% 1694 3.1% 766 7.4%

Hutt Valley 321 3.6% 1551 2.8% 605 5.9%

Lakes 412 4.6% 1034 1.9% 336 3.3%

MidCentral 349 3.9% 1771 3.2% 427 4.1%Nelson Marlborough 130 1.5% 1540 2.8% 534 5.2%

Northland 374 4.2% 2038 3.7% 745 7.2%South Canterbury 94 1.0% 483 0.9% 152 1.5%

Southern 892 10.0% 2758 5.0% 740 7.2%

Tairawhiti 179 2.0% 641 1.2% 239 2.3%

Taranaki 327 3.6% 1302 2.4% 363 3.5%

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2017 2012







RespondentsWaikato 1248 13.9% 5251 9.5% 737 7.2%

Wairarapa 131 1.5% 514 0.9% 92 0.9%

Waitemata 945 10.5% 5147 9.4% 662 6.4%

West Coast 50 0.6% 582 1.1% 143 1.4%

Whanganui 147 1.6% 745 1.4% 168 1.6%

Missing 0 0.0% 0 0.0% 0 0.0%

Profession Allied/Other 2670 29.8% 11469 20.8% 3483 33.8%

Doctor 1742 19.4% 9081 16.5% 1912 18.6%

Midwife 343 3.8% 1386 2.5% 327 3.2%

Nurse 4089 45.6% 26661 48.4% 4573 44.4%

Missing 119 1.3% 0 0.0% 8 0.1%

Age 20-29 781 8.7% 8284 15.1% 861 8.4%

30-39 1325 14.8% 11375 20.7% 1728 16.8%

40-49 1993 22.2% 11093 20.2% 2832 27.5%

50-59 2553 28.5% 11429 20.8% 2838 27.5%

60 or over 1133 12.6% 6285 11.4% 917 8.9%

Missing 1178 13.1% 121 0.2% 1127 10.9%

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2017 2012







RespondentsExperienceUnder 5 years 1439 16.1% 23171 42.1% 1839 17.8%

5-15 years 2793 31.2% 16144 29.3% 3367 32.7%More than 15 years 3568 39.8% 9282 16.9% 3975 38.6%

Missing 1163 13.0% 0 0.0% 1122 10.9%

Sex Female 6136 68.5% 38407 69.8% 7135 69.3%

Male 1656 18.5% 10183 18.5% 2042 19.8%

Missing 1171 13.1% 7 0.0% 1126 10.9%

Total 8963 100.0% 48597 88.3% 10303 100.0%

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2Responserates

2.1ByDHB

2017 2012

DHB Number of Respondents DHB Workforce Response Rate Response Rate

Auckland 578 8603 6.7% 22.7%

Bay of Plenty 508 3324 15.3% 22.4%

Canterbury 422 6896 6.1% 0.0%

Capital and Coast 346 4346 8.0% 35.7%

Counties Manukau 1051 4816 21.8% 6.6%

Hawke's Bay 459 1694 27.1% 48.0%

Hutt Valley 321 1551 20.7% 37.1%

Lakes 412 1034 39.8% 40.9%

MidCentral 349 1771 19.7% 23.4%

Nelson Marlborough 130 1540 8.4% 40.7%

Northland 374 2038 18.4% 35.5%

South Canterbury 94 483 19.5% 33.3%

Southern 892 2758 32.3% 30.0%

Tairawhiti 179 641 27.9% 49.1%

Taranaki 327 1302 25.1% 34.6%

Waikato 1248 5251 23.8% 19.7%

Wairarapa 131 514 25.5% 25.6%

Waitemata 945 5147 18.4% 14.1%

West Coast 50 582 8.6% 20.5%

Whanganui 147 745 19.7% 25.0%

Total 8963 48597 18.4% 25.1%

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2.2ByProfession

2017 2012

Job Number of Respondents Number in Workforce Response Rate Response Rate

Allied/Other 2670 11469 23.3% 38.7%

Doctor 1742 9081 19.2% 25.1%

Midwife 343 1386 24.7% 21.5%

Nurse 4089 26661 15.3% 19.4%

Total 8963 48597 18.4% 25.1%

Note:‘Midwife’doesnotincludecommunity-basedLM

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3QuestionsbyDHB

3.1Clinicalleadershipisdescribedas‘anewobligationtostepup,workwithotherleaders,bothclinicalandmanagerial,andchangethesystemwhereitwouldbenefitpatients’.Howfamiliarareyouwiththisconcept?

Overall,4475(50.5%;2012=47%)respondentswerefamiliarwiththeconcept.ThemeanacrossDHBswas51.4%(SD:4.3%).Familiarityrangedfrom43.8%(Waikato)to62.3%(NelsonMarlborough).

8869(99%)Respondentsansweredthisquestion.

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3.1aClinicalleadershipisdescribedas‘anewobligationtostepup,workwithotherleaders,bothclinicalandmanagerial,andchangethesystemwhereitwouldbenefitpatients’.Howfamiliarareyouwiththisconcept?(2012and2017compared)

47.1%ofrespondentsin2012reportedthattheywerefamiliarwiththeconceptofclinicalleadershipcomparedto50.3%ofrespondentsin2017(anabsoluteincreaseof3.2%).ThemeanforDHBsincreased(48.2%vs51.9%).Themeandifferenceinthepercentageofrespondentsgivinga‘familiar’responsetothisquestionacrossDHBswas3.7%(SD:5%).NelsonMarlboroughhadthegreatestincreaseby2017(15%)andWairarapahadthegreatestdecrease(-5.3%).

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3.2TowhatextentdoyoubelievethatyourDHBhasworkedtoenablestrongclinicalleadershipanddecisionmakingthroughouttheorganisation?

Overall,6792(77%;2012=78%)respondentsfelttheirDHBwasworkingtoenablestrongclinicalleadershipanddecisionmakingthroughouttheorganisation.ThemeanacrossDHBswas76.3%(SD:4.9%).Agreementrangedfrom66.5%(Tairawhiti)to85%(Whanganui).

8819(98.4%)Respondentsansweredthisquestion.

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3.2aTowhatextentdoyoubelievethatyourDHBhasworkedtoenablestrongclinicalleadershipanddecisionmakingthroughouttheorganisation?(2012and2017compared)

77.7%ofrespondentsin2012reportedthattheybelievedtheirDHBhadworkedtoenablestrongclinicalleadershipanddecisionsmakingthroughouttheorganisationtosomeoragreatextentcomparedto76.7%ofrespondentsin2017(anabsolutedecreaseof0.9%).ThemeanforDHBsdecreased(77.9%vs77.5%).Themeandifferenceinthepercentageofrespondentsgivinga‘someorgreatextent’responsetothisquestionacrossDHBswas-0.4%(SD:6.6%).WestCoasthadthegreatestincreaseby2017(11.3%)andTairawhitihadthegreatestdecrease(-15.2%).

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3.3Toyourknowledge,doesyourDHBhaveanestablishedgovernancestructurethatensuresapartnershipbetweenhealthprofessionalsandmanagement?

Overall,4278(48.3%;2012=45%)respondentsthoughttheirDHBhasanestablishedgovernancestructurethatensurespartnershipbetweenhealthprofessionalsandmanagement.ThemeanacrossDHBswas48.9%(SD:6.6%).Agreementrangedfrom33.6%(Southern)to58.5%(NelsonMarlborough).


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3.3aToyourknowledge,doesyourDHBhaveanestablishedgovernancestructurethatensuresapartnershipbetweenhealthprofessionalsandmanagement?(2012and2017compared)

44.9%ofrespondentsin2012reportedthattheirDHBhadanestablishedgovernancestructurethatensuredapartnershipbetweenhealthprofessionalsandmanagementcomparedto48%ofrespondentsin2017(anabsoluteincreaseof3.1%).ThemeanforDHBsincreased(45.8%vs49.2%).Themeandifferenceinthepercentageofrespondentsgivinga‘yes’responsetothisquestionacrossDHBswas3.4%(SD:8.3%).WestCoasthadthegreatestincreaseby2017(16.8%)andSouthCanterburyhadthegreatestdecrease(-9.2%).

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3.4TowhatextenthasmanagementwithinyourDHBsoughttofosterandsupportthedevelopmentofclinicalleadership?

Overall,5998(67.3%;2012=63%)respondentsfelttheirDHBhadsoughttofosterandsupportthedevelopmentofclinicalleadership.ThemeanacrossDHBswas67.7%(SD:5.3%).Agreementrangedfrom58.1%(Tairawhiti)to74.5%(SouthCanterbury).


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3.4aTowhatextenthasmanagementwithinyourDHBsoughttofosterandsupportthedevelopmentofclinicalleadership?(2012and2017compared)

63.3%ofrespondentsin2012reportedthatmanagementintheirDHBhadsoughttofosterandsupportthedevelopmentofclinicalleadershiptosomeoragreatextentcomparedto67.1%ofrespondentsin2017(anabsoluteincreaseof3.8%).ThemeanforDHBsincreased(64.1%vs68%).Themeandifferenceinthepercentageofrespondentsgivinga‘someorgreatextent’responsetothisquestionacrossDHBswas3.9%(SD:7.3%).WestCoasthadthegreatestincreaseby2017(19.9%)andTairawhitihadthegreatestdecrease(-9.4%).

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3.5TowhatextenthaveyoubeeninvolvedinworkingwithotherDHBstaff,bothclinicalandmanagerial,tochangethesystemwhereitwouldbenefitpatients?

Overall,5551(67.5%;2012=75%)respondentsfelttheyhadbeeninvolvedinworkingwithotherDHBstaff,bothclinicalandmanagerial,tochangethesystemwhereitwouldbenefitpatients.ThemeanacrossDHBswas64%(SD:6.1%).Agreementrangedfrom54.1%(Taranaki)to76.9%(NelsonMarlborough).


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3.6TowhatextentarehealthprofessionalsinyourDHBinvolvedinapartnershipwithmanagementwithshareddecisionmaking,responsibilityandaccountability?

Overall,5632(68.6%;2012=71%)respondentsfeltthathealthprofessionalsintheirDHBwereinvolvedinvolvedinapartnershipwithmanagementwithshareddecisionmaking,responsibilityandaccountability.ThemeanacrossDHBswas64.1%(SD:5.1%).Agreementrangedfrom54.7%(Tairawhiti)to72%(WestCoast).


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3.6aTowhatextentarehealthprofessionalsinyourDHBinvolvedinapartnershipwithmanagementwithshareddecisionmaking,responsibilityandaccountability?(2012and2017compared)

71.3%ofrespondentsin2012reportedthathealthprofessionalsintheirDHBwereinvolvedinapartnershipwithmanagementwithshareddecisionmaking,responsibilityandaccountabilitytosomeoragreatextentcomparedto68.4%ofrespondentsin2017(anabsolutedecreaseof2.9%).ThemeanforDHBsdecreased(71.6%vs69.5%).Themeandifferenceinthepercentageofrespondentsgivinga‘someorgreatextent’responsetothisquestionacrossDHBswas-2.1%(SD:6.7%).WestCoasthadthegreatestincreaseby2017(9.1%)andTairawhitihadthegreatestdecrease(-18.3%).

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3.7TowhatextentarehealthprofessionalsinyourDHBinvolvedasfullactiveparticipantsinthedesignoforganisationalprocesses?

Overall,4840(59.5%;2012=61%)respondentsfeltthathealthprofessionalsintheirDHBwereinvolvedasfullactiveparticipantsinthedesignoforganisationalprocesses.ThemeanacrossDHBswas55.8%(SD:6.8%).Agreementrangedfrom46.9%(Tairawhiti)to68.1%(SouthCanterbury).


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3.7aTowhatextentarehealthprofessionalsinyourDHBinvolvedasfullactiveparticipantsinthedesignoforganisationalprocesses?(2012and2017compared)

61.5%ofrespondentsin2012reportedthathealthprofessionalsintheirDHBwereinvolvedasfullactiveparticipantsinthedesignoforganisationalprocessestosomeoragreatextentcomparedto59%ofrespondentsin2017(anabsolutedecreaseof2.4%).ThemeanforDHBsdecreased(62.8%vs60.8%).Themeandifferenceinthepercentageofrespondentsgivinga‘someorgreatextent’responsetothisquestionacrossDHBswas-2%(SD:7%).BayofPlentyhadthegreatestincreaseby2017(7.5%)andTairawhitihadthegreatestdecrease(-17%).

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3.8TowhatextenthasyourDHBsoughttogiveresponsibilitytoyourteamforclinicalservicedecisionmakinginyourclinicalareas?

Overall,5302(64.9%;2012=69%)respondentsfeltthattheirDHBhadsoughttogiveresponsibilitytotheirteamforclinicalservicedecisionmakingintheirclinicalareas.ThemeanacrossDHBswas60%(SD:5%).Agreementrangedfrom51.4%(Taranaki)to69.4%(Whanganui).


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3.8aTowhatextenthasyourDHBsoughttogiveresponsibilitytoyourteamforclinicalservicedecisionmakinginyourclinicalareas?(2012and2017compared)

69.5%ofrespondentsin2012reportedthattheirDHBhadsoughttogiveresponsibilitytotheirteamforclinicalservicedecisionmakingintheirclinicalareastosomeoragreatextentcomparedto64.9%ofrespondentsin2017(anabsolutedecreaseof4.5%).ThemeanforDHBsdecreased(69.9%vs65.7%).Themeandifferenceinthepercentageofrespondentsgivinga‘someorgreatextent’responsetothisquestionacrossDHBswas-4.2%(SD:6.2%).Whanganuihadthegreatestincreaseby2017(11%)andTairawhitihadthegreatestdecrease(-16.5%).

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3.9TowhatextentdoesyourDHBprovidesufficientsupportforyoutoengageinclinicalleadershipactivities?

Overall,4821(58.7%;2012=36%)respondentsfeltthattheirDHBprovidedsufficientsupportforthemtoengageinclinicalleadershipactivities.ThemeanacrossDHBswas55%(SD:6.2%).Agreementrangedfrom42.5%(Taranaki)to68%(WestCoast).


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3.10Towhatextentdoesyourclinicalservicesharepatientoutcomedatawiththecommunityitserves?

Overall,3565(44.9%;2012=notasked)respondentsfeltthattheirclinicalservicesharedpatientoutcomedatawiththecommunityitserves.ThemeanacrossDHBswas40.7%(SD:6.1%).Agreementrangedfrom31.5%(NelsonMarlborough)to56.5%(Whanganui).


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3.11TowhatextentdoesyourDHBsharepatientoutcomedatawiththecommunityitserves?

Overall,4169(52.6%;2012=notasked)respondentsfeltthattheirDHBsharedpatientoutcomedatawiththecommunityitserves.ThemeanacrossDHBswas48.6%(SD:7.6%).Agreementrangedfrom38.5%(NelsonMarlborough)to66%(Whanganui).


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3.12ThisDHBexplicitlydefineshealthprofessionalrolesinadvancingpatientsafetyinjobdescriptionsandorientation,andinrequiringcontinuingprofessionaleducation.

Overall,4556(57.5%;2012=notasked)respondentsfeltthattheirDHBexplicitlydefineshealthprofessionalrolesinadvancingpatientsafetyinjobdescriptionsandorientation,andinrequiringcontinuingprofessionaleducation.ThemeanacrossDHBswas51.1%(SD:5.4%).Agreementrangedfrom43%(Tairawhiti)to65.3%(Whanganui).


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3.13HealthprofessionalsinthisDHBworktogetherasawell-coordinatedteam.

Overall,4519(57.4%;2012=57%)respondentsagreethathealthprofessionalsintheirDHBworktogetherasawell-coordinatedteam.ThemeanacrossDHBswas51%(SD:6.9%).Agreementrangedfrom31.3%(Tairawhiti)to60%(WestCoast).


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3.13aHealthprofessionalsinthisDHBworktogetherasawell-coordinatedteam(2012and2017compared).

57.1%ofrespondentsin2012agreedslightlyorstronglywiththestatementthathealthprofessionalsintheirDHBworktogetherasawell-coordinatedteamcomparedto57.4%ofrespondentsin2017(anabsoluteincreaseof0.3%).ThemeanforDHBsincreased(57.3%vs57.6%).ThemeandifferenceinthepercentageofrespondentsagreeingtothisstatementacrossDHBswas0.3%(SD:8.4%).WestCoasthadthegreatestincreaseby2017(17.2%)andTairawhitihadthegreatestdecrease(-20.2%).

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3.14HealthprofessionalsinthisDHBinvolvepatientsandfamiliesineffortstoimprovepatientcare.

Overall,5760(73.2%;2012=70%)respondentsagreethathealthprofessionalsintheirDHBinvolvepatientsandfamiliesineffortstoimprovepatientcare.ThemeanacrossDHBswas64.7%(SD:5.9%).Agreementrangedfrom49.7%(Tairawhiti)to75.5%(Whanganui).


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3.14aHealthprofessionalsinthisDHBinvolvepatientsandfamiliesineffortstoimprovepatientcare(2012and2017compared).

69.5%ofrespondentsin2012agreedslightlyorstronglywiththestatementthathealthprofessionalsintheirDHBinvolvepatientsandfamiliesineffortstoimprovepatientcarecomparedto73.1%ofrespondentsin2017(anabsoluteincreaseof3.6%).ThemeanforDHBsincreased(70.5%vs72.9%).ThemeandifferenceinthepercentageofrespondentsagreeingtothisstatementacrossDHBswas2.4%(SD:7.2%).WestCoasthadthegreatestincreaseby2017(10.2%)andTairawhitihadthegreatestdecrease(-21.6%).

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3.15Inthisclinicalarea,itiseasytospeakupifIperceiveaproblemwithpatientcare.

Overall,5072(64.5%;2012=69%)respondentsagreethat,intheirclinicalarea,itiseasytospeakupiftheyperceiveaproblemwithpatientcare.ThemeanacrossDHBswas57.7%(SD:5.5%).Agreementrangedfrom49.2%(Tairawhiti)to71%(Wairarapa).


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3.15aInthisclinicalarea,itiseasytospeakupifIperceiveaproblemwithpatientcare(2012and2017compared).

68.7%ofrespondentsin2012agreedslightlyorstronglywiththestatementthat,intheirclinicalarea,itiseasytospeakupiftheyperceiveaproblemwithpatientcareintheirDHBcomparedto64.5%ofrespondentsin2017(anabsolutedecreaseof4.3%).ThemeanforDHBsdecreased(68.8%vs65.2%).ThemeandifferenceinthepercentageofrespondentsagreeingtothisstatementacrossDHBswas-3.6%(SD:5.1%).Lakeshadthegreatestincreaseby2017(4.1%)andTairawhitihadthegreatestdecrease(-16.7%).

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4QuestionsbyProfession

4.1Clinicalleadershipisdescribedas‘anewobligationtostepup,workwithotherleaders,bothclinicalandmanagerial,andchangethesystemwhereitwouldbenefitpatients’.Howfamiliarareyouwiththisconcept?

Mostrespondentswerefamiliarwiththeconceptofclinicalleadership.FamiliaritywashighestinDoctor(64.6%)andlowestinAllied/Other(44%).In2012,doctorswerealsothehighest.

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4.2TowhatextentdoyoubelievethatyourDHBhasworkedtoenablestrongclinicalleadershipanddecisionmakingthroughouttheorganisation?

ThevastmajorityofrespondentsbelievedthattheirDHBhasworkedtoenablestrongclinicalleadershipanddecisionmakingthroughouttheorganisation.ThiswashighestinNurse(77.2%)andlowestinAllied/Other(74.6%).In2012,nurseswereslightlyhigher.

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4.3Toyourknowledge,doesyourDHBhaveanestablishedgovernancestructurethatensuresapartnershipbetweenhealthprofessionalsandmanagement?

JustunderhalfofrespondentsthoughtthattheirDHBhadanestablishedgovernancestructurethatensuredapartnershipbetweenhealthprofessionalsandmanagement.ThiswashighestinAllied/Other(50.2%)andlowestinNurse(46%).In2012,doctorsandalliedprofessionalswerethehighest.

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4.4TowhatextenthasmanagementwithinyourDHBsoughttofosterandsupportthedevelopmentofclinicalleadership?

OverhalfofrespondentsagreedthatmanagementwithintheirDHBsoughttofosterandsupportthedevelopmentofclinicalleadership.ThiswashighestinMidwife(69.1%)andlowestinAllied/Other(63.7%).In2012,alliedprofessionalswerealsothelowest.

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4.5TowhatextenthaveyoubeeninvolvedinworkingwithotherDHBstaff,bothclinicalandmanagerial,tochangethesystemwhereitwouldbenefitpatients?

ThemajorityofrespondentsreportedthattheywereinvolvedinworkingwithotherDHBstaff,bothclinicalandmanagerial,tochangethesystemwhereitwouldbenefitpatients.ThiswashighestinDoctor(73%)andlowestinNurse(58.2%).In2012,doctorswerealsothehighest.

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4.6TowhatextentarehealthprofessionalsinyourDHBinvolvedinapartnershipwithmanagementwithshareddecisionmaking,responsibilityandaccountability?

AroundhalfofrespondentsreportedthathealthprofessionalsintheirDHBwereinvolvedinapartnershipwithmanagementwithshareddecisionmaking,responsibilityandaccountability.ThiswashighestinDoctor(69.3%)andlowestinMidwife(60.3%).In2012,doctorswerealsothehighest.

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4.7TowhatextentarehealthprofessionalsinyourDHBinvolvedasfullactiveparticipantsinthedesignoforganisationalprocesses?

JustoverhalfofrespondentsreportedthathealthprofessionalsintheirDHBwereinvolvedasfullactiveparticipantsinthedesignoforganisationalprocesses.ThiswashighestinDoctor(60%)andlowestinMidwife(51.6%).In2012,midwiveswerealsothelowest.

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4.8TowhatextenthasyourDHBsoughttogiveresponsibilitytoyourteamforclinicalservicedecisionmakinginyourclinicalareas?

JustoverhalfofrespondentsreportedthattheirDHBhadsoughttogiveresponsibilitytotheirteamforclinicalservicedecisionmakingintheirclinicalareas.ThiswashighestinDoctor(62.2%)andlowestinMidwife(58%).In2012,nurseswerethehighest.

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4.9TowhatextentdoesyourDHBprovidesufficientsupportforyoutoengageinclinicalleadershipactivities?

JustoverhalfofrespondentsfeltthattheirDHBprovidedsufficientsupportforthemtoengageinclinicalleadershipactivities.ThiswashighestinMidwife(61.8%)andlowestinAllied/Other(51%).In2012,doctorswereslightlymorelikelythantheotherstoreportinsufficientsupport.

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4.10Towhatextentdoesyourclinicalservicesharepatientoutcomedatawiththecommunityitserves?

Comparativelyfewrespondentsreportedthattheirclinicalservicesharedpatientoutcomedatawiththecommunityitserved.ThiswashighestinMidwife(56.3%)andlowestinDoctor(32.3%).Thisquestionwasnotincludedin2012.

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4.11TowhatextentdoesyourDHBsharepatientoutcomedatawiththecommunityitserves?

AroundhalfofrespondentsreportedthattheirDHBsharedpatientoutcomedatawiththecommunityitserved.ThiswashighestinMidwife(51.6%)andlowestinDoctor(41.4%).Thisquestionwasnotincludedin2012.

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4.12ThisDHBexplicitlydefineshealthprofessionalrolesinadvancingpatientsafetyinjobdescriptionsandorientation,andinrequiringcontinuingprofessionaleducation.

JustoverhalfofrespondentsagreedthattheirDHBexplicitlydefinedhealthprofessionalrolesinadvancingpatientsafetyinjobdescriptionsandorientation,andinrequiringcontinuingprofessionaleducation.ThiswashighestinMidwife(60.1%)andlowestinDoctor(41.4%).Thisquestionwasnotincludedin2012.

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4.13HealthprofessionalsinthisDHBworktogetherasawell-coordinatedteam.

JustoverhalfofrespondentsagreedthathealthprofessionalsintheirDHBworktogetherasawell-coordinatedteam.ThiswashighestinDoctor(54.9%)andlowestinMidwife(48.1%).In2012,midwiveswerethehighestscoringgroup;theotherthreegroupswerethesame.

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4.14HealthprofessionalsinthisDHBinvolvepatientsandfamiliesineffortstoimprovepatientcare.

ThemajorityofrespondentsagreedthathealthprofessionalsintheirDHBinvolvedpatientsandfamiliesineffortstoimprovepatientcare.ThiswashighestinNurse(65.8%)andlowestinMidwife(62.7%).In2012,nurseswerethehighestscoringgroup,withmidwivessecond.

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4.15Inthisclinicalarea,itiseasytospeakupifIperceiveaproblemwithpatientcare.

Justoverhalfofrespondentsagreedthat,intheirclinicalarea,itwaseasytospeakupiftheyperceivedaproblemwithpatientcare.ThiswashighestinDoctor(59.4%)andlowestinAllied/Other(52.4%).In2012,nurseswerethehighestscoringgroup.

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WrittencommentsfromrespondentsAtotalof2497writtencommentswerereceivedfromthe8963respondents(therefore,from27.8%ofrespondents),amountingtoover180pagesoftext.Analysesindicateover95%ofwrittencommentswerecritical,withnodifferencebyDHB,althoughmanycriticalcommentscamefromrespondentswhoseanswerstothemainsurveyquestionsweremorepositivethantheircommentswouldimply.Itispossiblethatrespondentswithnegativeorcriticalcommentsweremoremotivatedtoexpresstheirviews.Belowarerepresentativequotes,bothcriticalandsupportiveofclinicalgovernanceandqualityactivitiesinDHBs.Criticalcomments ‘Although the structures are in place clinical leadership is often compromised by the competing demands of clinical work and the time imperative of ongoing change. Major decisions are still made by a few service leaders with middle level managers and clinicians often required to demonstrate 'leadership' by implementing changes that they don't completely understand or agree with. There is a lack of senior clinicians to provide clinical guidance and supervision to less experienced clinicians who are frequently put in clinical situations beyond their skill levels.’ ‘It would be good if junior staff were involved more. Seems than often co-ordination between clinical and managerial staff occurs at a senior level, with little involvement or suggestions sought from more junior staff who, in reality, are more involved with the day to day aspects of patient care and safety. Another issues that prevents engagement with clinical leadership is time constraints - perhaps people would engage more if specified time was set aside for this?’ ‘Leadership by clinicians is not valued in my DHB and management follow their own agenda, rather than those that matter to clinicians and patients. When safety issues are raised immediate action is rarely taken, definitive responses are extremely slow and root causes rarely addressed. This should be the other way round with clinicians leading and management supporting clinical priorities.’ ‘There is a top-down style of leadership in my DHB. Too many ill thought out changes have been made despite sound objections raised by clinical staff. As a result, staff are disillusioned and morale is very low.’ ‘Sometimes I feel that we would do better for patient care if there was a means to feedback ideas for quality improvement/ways to save money/improve staff morale to senior management.’ ‘Leadership is generally poor. Robust decision making is not the norm. We tend to jump from one crisis to another without taking stock. The concept of Clinical Governance is unknown to most clinicians. Middle level managers are unsupported in decision making by their senior managers, who tend not to want to appear unpopular.’

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Supportivecomments‘The emphasis on creating a culture among staff that encourages communication and proactive ideas and behaviors is a strength in this DHB that I have not had elsewhere.’ ‘[this DHB] has engaged clinicians in leadership to a large extent. The constraints are mostly those imposed by the Government and are mostly related to funding.’ ‘I feel this DHB has made great moves in the last 10 years to involve the community it serves in improving service delivery and offers staff endless opportunity for education and participation in clinical leadership.’ DiscussionKeyfindingsThisstudyprovidesanupdateonprogresswithdevelopingclinicalgovernance,andonhealthprofessionalperceptionsofaspectsofthequalityandsafetyenvironmentinNewZealandDHBs.Thestudybringsanimportantcross-sectorcomparativedimension,duetoitsnationalcoverageandinclusionofall20DHBs.Italsoallowsforgaugingprogressovertime,giventheprior2012studywhichprovidedbaselinedata.Perhaps,mostnotably,limitedprogresshasbeenmadesince2012.In2017,slightlymorefamiliaritywiththeconceptofclinicalleadershipwasfoundthanin2012(table3.1a).TherewasamarginaldecreaseinextenttowhichrespondentsbelievedtheirDHBwasworkingtoenablestrongclinicalleadershipanddecisionmaking(tables3.2a).TherewasaslightimprovementintheextenttowhichrespondentsperceivedDHBshadsoughttofosterandsupportclinicalleadership(3.4a),andaconsiderabledeclineinstaffreportingbeinginvolvedinworkingwithothersintheirDHBtochangethesystemwhereitwouldbenefitpatients(tables3.5;comparativetablewasnotgeneratedduetoslightwordingdifferencesbetween2012and2017survey).Therewasaslightdropinperceptionsofworkinginpartnershipwithmanagement,withshareddecisionmaking,responsibilityandaccountability(table3.6a;).3Thedeclinewasalsoreflectedinotherkeyquestions.Notably,however,thereappearedtobeasubstantialimprovementinrespondentsreportingthattheirDHBhadprovidedsufficientsupporttoengageinclinicalleadershipactivities,from36%in2012toalmost59%in2017(table3.9;comparativetablewasnotgeneratedduetoslightwordingdifferencesbetween2012and2017survey).ThisisdespiteanoftenveryconstrainedfundingenvironmentintheDHBsector.Asnoted,onlyfouroftheClinicalGovernanceDevelopmentIndex(CGDI)questionsfromthe2012surveywererepeatedinthe2017survey.Ofthese,theoverallmeanpositiveresponsesforDHBsdecreasedslightlybetween2012and2017forthreeofthefourquestions.Additionally,foreachofthesethreequestions,mostoftheDHBsshowedadecreasebetween2012and2017(elevenDHBsfor‘Towhatextentarehealthprofessionals3Thequestionsrelatingtotables3.6and3.9werewordedslightlydifferentlyin2012and2017.Thedata,therefore,needtobetakenatfacevalueandcomparativetableshavenotbeengenerated.

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inyourDHBinvolvedinapartnershipwithmanagementwithshareddecisionmaking,responsibilityandaccountability?’throughtofifteenDHBsfor‘TowhatextentarehealthprofessionalsinyourDHBinvolvedinapartnershipwithmanagementwithshareddecisionmaking,responsibilityandaccountability?’).IftheremainderoftheCGDIquestionswereincluded,wewouldexpectthattheoverallCGDIscoresforDHBswouldhavedecreasedslightlyin2017.However,themagnitudeofdecreasesislargelyverysmall,anditislikelythattheyrepresenttheinfluenceofsamplingvariationanddifferingrespondentmixacrossthetwosurveysratherthanmeaningfulchangeinclinicalgovernancepractices.Onthethreenewquestionsdevelopedforthis2017study,asolidminorityofrespondentsbelievedtheirclinicalservicesharedpatientoutcomedatawiththecommunity(table3.10),whileaslightmajoritybelievedthattheirDHBdidso(table3.11).Thereasonsforthedifferencesinresponsetothesetwoquestionsremainunclearandwarrantfurtherinvestigation.OnepossibleexplanationisthatrespondentsperceivethatoutcomedataareincludedinDHBpublicationssuchasannualreportsandqualityaccounts.ItcouldbeusefultoinvestigatethemechanismsthroughwhichoutcomedataarereportedbyclinicalservicesandbyDHBs.OnlyalimitedmajorityofrespondentsbelievedtheirDHBincludedpatientsafetyinjobdescriptionsandcontinuingprofessionaleducationrequirements(table3.12).Responsestothethreequestionsonelementsofthepatientsafetyclimateweremixed.Therewasnochangeinperceptionsofteamwork(tables3.13a);someimprovementinperceptionsofinvolvingpatientsandfamiliesinimprovementeffortswasfound(tables3.14a);andtherewasadropinbeliefthatitiseasytospeakupwhenpatientcarelapsesareperceived(tables3.15a).Thislastfindingisperhapsofparticularconcern,giventheimportanceattachedtobuildingasafetycultureinwhichspeakingupisencouraged.24WhysomeDHBsappeartohaveimprovedonsomequestionsandothersnotremainsanimportantquestion.Tairawhiti,forexample,wasamongstthebetterperformingDHBsin2012butsinceappearstohavedeclinedsomewhatonalmosteverycomparablequestion.Furtherinvestigationintothiscouldbeuseful.AhandfulofDHBsappeartohaveconsisentlyimprovedperformanceacrossseveralquestionssince2012,includingAuckland,BayofPlenty,HawkesBay,WestCoastandWhanganuialthough,again,therearevariationsinperformanceacrossquestions,whileotherDHBsimprovedonindividualquestions.LimitationsTheresearchpresentedinthisreporthasvariouslimitations.First,thesurveymethodthatunderpinstheanalysesisoftensubjecttocritique.Surveymethodsarewidelyused,yetfixed-responsequestionsarealwaysopentoindividualrespondentinterpretations.Individualsurveyquestionsalsoonlyprobethespecificareastheyaretargetedat.Tocomplementthefixed-answerquestions,anopen-endedcommentsboxwasalsoincludedinthesurveytoallowforrespondentstooffertheirownthoughts.Thisprovidedrichdata,someofwhichwerepresentedinthisreport.Similardatafromtheearlier2012studywerereportedoninapublishedjournalarticle.12Second,thesurveyresponseratewouldideallyhavebeenconsiderablyhigher.Tooffsetresponserateconcerns,thedatasetislargeandbroadlyrepresentativeofthehealth

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professionalworkforcewhichboostsconfidenceinthedata.Follow-upemailsweresentintheattempttoraiseresponseratesandsomeDHBsinvestedadditionaleffortintoboostingtheirstaffparticipation.SomeDHBsmadenoteofthefactthattheyhadconductedtheirownrecentstaffsurveysonsubjectssuchassafetycultureandorganisationalengagement.Forthisreason,theyfeltstaffcouldbefeeling‘surveyedout’,inturn,affectingtheresponserate.Giventhecomplicatednatureofthesurveyacross20DHBs,eachwithdifferentinternalstructures,andseveralprofessionalgroups,theresponseratecouldbeconsideredquitereasonableandcertainlyonaparwithresponseratesinothercomplexfieldsofpublichealthandhealthservicesresearch.25-27Third,thesurveymethoddeliversonlyquantitativedata(notingthatopencommentswerecollectedinthissurveyaswell).Whileimportantforgaugingperceptions,andestablishingabaselineagainstwhichtocomparefuturestudies,itcouldbeusefultofurtherinvestigateseveraloftheissueshighlightedbytheanalysisinthisreport–forexample,whyperceptionsofrespondentsinsomeDHBsappearstohavedeclined.Thiswouldperhapsbestbedonethroughqualitativemethods,suchasinterviewingandfocusgroupdiscussions,thatpermitin-depthexplorationofviewpointsandexperiences.The2012studydidincludein-depthcasestudiesofclinicalgovernanceandleadershipactivitiesin19DHBs,whichidentifiedaseriesofkeythemes.5,8Fourth,thedatapresentedinthisreportare‘raw’comparisons.Thatis,theydon’ttakeintoaccountthedifferentmixofrespondentsfromthetwodifferentsurveysin2012and2017.So,forexample,ifdoctorsrespondeddifferentlyfromnurses(andtheydo),andthe2017surveyhadmoredoctorsinitthanthe2012survey,thenanydifferenceinaDHBacrosstheyearscouldbesimplyduetothedifferentproportionofdoctorsintheDHB.Furtheranalysestolookintothisareplanned.ConclusionGoingintothe2010s,therewasastrongfocusonclinicalgovernanceandleadershipintheNewZealandhealthsector.The2012studydetectedconsiderablemomentumattheDHBlevel.Thefocusamongstnationalagenciesatthatpoint,however,wasinanembryonicstate,albeitstronglysupportive.OtherthantherecommendationsoftheMinisterialTaskGrouponClinicalLeadershipandaministerialstatement,2,6therewasnonationalpolicyorguidanceforclinicalgovernancedevelopment.Norwasthereaframeworkfordrivingperformanceinthisarea.TheDHBs,also,werevariedintermsoftheirunderstandingofclinicalgovernanceandleadershipanddevelopmentofmechanismsandmaterialstosupportthis.8Thefindingsofthe2017studydescribedinthisreportcouldbeareflectionofthissituation.Yettheprinciplesofclinicalgovernanceremainasimportantasever.HQSC’s2017adviceforthesectorconfirmsthisandencapsulatesaseriesofkeyfactorsthatprovidersshouldfocuson.21HQSC’sapproachhasprecedentselsewhere.Forexample,Ireland’sHealthServiceExecutive(acentralagencywithoversightofpublichospitalsandhealthcare)hashadaconcertedapproachtoclinicalgovernancedevelopment,withinabroaderpolicycontextofqualityimprovementandpatientsafety,datingbacktoatleasttheearly-2010s.A

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seriesofpolicydocumentsandpracticaladviceforthoseinvolvedindevelopingandimplementingclinicalgovernanceattheservicedeliverylevelandingovernanceroleshavebeenissued.28-32Thishasincludedadviceforhealthboardsaswellasmanagersandhealthprofessionals.Tobefair,Ireland’shealthsystemisorganisedinawaythatprovidesamuchstrongercapacitythanNewZealandtodrivepolicydevelopmentsfromthecentre;inotherwords,togaintheparticipationofpublichospitalsandhealthservicesinnationalinitiatives.ResearchsuggeststhatIreland’smorecentralisedapproachandmandatetodrivepolicyinitiativescouldbemoreeffectiveandworthreplicatinginNewZealand.14IfclinicalgovernanceinNewZealandistoadvance,thereisarguablyademandforamoresupportiveenvironmentforthis.Thismeansencouragementandsupportfromacrossthesector,withadviceandguidancefromthecentreaswellasclearcommitmentandsupportfromtheDHBs.Ofcourse,healthprofessionalsalsohavearesponsibilityforenablinganddevelopingclinicalgovernance.1,33Asthestewardsofpatientsafety,intheirroleasfrontlineserviceproviders,theyhaveanobligationonbehalfofeverypatientandthebroadersystemwithinwhichtheydelivercaretostepupandworkwithothers,includingotherprofessionalsandmanagers,andengageinimprovementactivities.Progressgenerallyrequiressettingupmeasuresforholdingindividualsandthesystemtoaccount.Inthisregard,studiessuchasthisonearecriticaltomeasuringdevelopmentaswellashighlightingareaswhereworkisneeded.HQSCistobecommendedforfocusingonthisaspect.Itwouldbeusefulforthisfocustobroadentoinvolveothercentralagencies.AcknowledgementsWearegratefultoHQSCforcommissioningthisstudy;totheDHBsfortheirwillingparticipationandassistancewithsurveyadministration;andtothemanythousandsofbusyhealthprofessionalswhotookjustover4mins(onaverage)outoftheirschedulestocompletethissurvey.Weareindebtedtoyouallanddeeplyvalueyourparticipation.

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