Views from the executive suite: lessons from the introduction of performance management

The Clinical Services Redesign Program in New South Wales: perceptions of senior health managers

Objective.This study explores the views of senior managers regarding their experience of participating in the Clinical Services Redesign Program (CSRP) in New South Wales and the impact of that Program. Methods.Semi-structured interviews were conducted in 2007 with 42 senior managers working in the NSW health system. Results.Managers reported being increasingly oriented towards efficiency, achieving results and using data to support decision-making. The increased focus on managing performance was accompanied by concerns about the narrowness of the indicators being used to manage performance and how these are applied. The value placed by interviewees on the use of ‘competition’ as a lever for improving services varied. Leadership was repeatedly identified as important for long-term success and sustainability. No one was confident that the CSRP had yet been sufficiently embedded in day to day practice in order for it to keep going on its own. Conclusion.Our findings are generally consistent with the extensive literature on change management, performance management and leadership. Some cultural change has taken place in terms of observed patterns of behaviour but it is unrealistic to think that CSRP can on its own deliver the desired deeper cultural changes in the values and assumptions underpinning the NSW Health system. There is some evidence of dysfunctional aspects of performance management but no call for the focus on performance or redesign to be abandoned. What is known about the topic?There has been growing interest internationally in the potential of industrial process improvement models (such as business process re-engineering, Six Sigma and Lean Manufacturing) to secure sustained improvements in the efficiency of healthcare services. Such approaches are often accompanied by the implementation of a rigorous performance management system. However, overall results in the healthcare sector have been mixed with outcomes sometimes falling short of stated ambitions. To date, in-depth research into the use of such approaches and systems in Australia has been limited. What does this paper add?This paper reports on research in New South Wales to evaluate one such approach: the 3-year Clinical Services Redesign Program that aims to achieve transformational, sustainable, system-wide change by ‘undertaking deep seated structural and cultural reform of traditional work practices’. The original CSRP business case envisaged a radical – rather than incremental – approach to system change, in keeping with a ‘re-engineering’ ethos. The qualitative findings presented here are based on interviews in 2007 with 42 senior health managers working at different levels of the health system. These interviews explored the experience of participating in the CSRP and elicited views as to the perceived impact of the Program from a managerial perspective. The findings are related to theories of system level change and compared with the emerging evidence-base relating to large-scale improvement strategies in healthcare. What are the implications for practitioners?Managers support the principle of managing performance by setting targets, with concerns primarily about the narrow focus of the selected targets, how the targets are applied locally and the nature of their central monitoring. Targets need to be well defined and measure the processes and outcomes that really matter. The principle of linking performance with service redesign was also supported. However, interviewees did not believe that changing culture to achieve sustainable change could be brought about by a single centrally-led change program. Significantly, leadership was seen as a critical factor in improving performance but needs to be considered within a broad framework (i.e. a system of leadership) that relies on more than just the attributes of individuals. Finally, management development should not be overlooked, or seen as less important than leadership development. Improvement projects frequently fail in implementation and this is as much a management issue as a leadership issue.