# Voice of the Clinician: the case of an Australian health system

Mark J. Lock (Committix Pty Ltd, Newcastle, Australia)
Amber L. Stephenson (School of Business, Clarkson University, Schenectady, New York, USA)
Jill Branford (Mid North Coast Local Health District, Coffs Harbour, Australia)
Jonathan Roche (Clinical Governance Unit, Mid North Coast Local Health District, Coffs Harbour, Australia)
Marissa S. Edwards (UQ Business School, The University of Queensland, Brisbane, Australia)
Kathleen Ryan (Mid North Coast Local Health District, Coffs Harbour, Australia)

ISSN: 1477-7266

Publication date: 18 September 2017

## Abstract

### Purpose

The Voice of the Clinician project commenced during an era when practitioner burnout, dissatisfaction, and turnover became an increasingly global health workforce concern. One key problem is clinical staff not being empowered to voice their concerns to decision-makers, as was found in this case study of an Australian public health organization. The following research question informed the present study: What is a better committee system for clinician engagement in decision-making processes? The paper aims to discuss this issue.

### Design/methodology/approach

The Mid North Coast Local Health District in New South Wales aspired to improve engagement between frontline clinicians and decision-makers. Social network analysis methods and mathematical modeling were used in the discovery of how committees are connected to each other and subsequently to other committee members.

### Committee interlock network

Networks offer a complementary view to hierarchies, where, analogous to that of a spider’s web, clinicians may have their views heard through being interconnected to other knowledge brokers. The key point is that individuals may be members of more than one committee, in social network terms this is called an “interlock” (Butts, 2008). The main interlock graph (Figure 2) is constructed from membership data from 323 committees and 926 committee members, which equates to 3,159 links, a vastly different representation to that of the formal links in the Figure 1. The key finding is that all 926 committee members were interlinked into the decision-making structures, this contrasts to the hierarchy, where the committees and committee members of the “vacuum” appear disconnected. This means that clinicians may influence decision-making processes through their connectedness, although whether or not this occurs is another subject for future investigation.

As is evident from Figure 2, the committee interlock data are also extremely difficult to visualize in print, which are discussed later in the development of the CVH. Nevertheless, some general topographical features are evident. The overall structure has a dense core to which a large number of links are generated from the periphery. Clearly, some committees (grey squares) and committee members (various shapes) are more interconnected into the decision-making structures of the MNCLHD. Whether this converts into greater levels of influence, or greater levels of information overload, requires more investigation. However, a key informant noted that most of the frontline clinicians are located at the periphery of the network and often had just one link to a committee. Managers are more connected whilst directors and executives have multiple connections and occupy the core of the interlock network, as can be seen in Figure 3.

As such, Figure 3 shows the examination of different segments of the committee interlock. The committees are grey squares, the members are the different shapes, where each shape represents a different clinician type (medical doctor, nurse, dietitian, etc.). The size of each symbol is equivalent to the number of links for each committee member. For example, clinician 1 has 35 links to committees, whilst clinician 2 has just five links to committees. That some committee members are more connected than others is represented in the average number of links (average n=3.4, range n=1-43, SD=4.8). That committees differ in the number of members is also evident in the size of the committee symbol (average n=10, range n=1-100, SD=10). Future analysis can reveal important insights into the relevance of this data for clinicians’ voice. It is also evident that reported data are imprecise with a committee having one member and another committee having 100 members. This is most likely due to poorly structured ToR. However, the data presented herein are the most accurate that are available and give the best estimate to date. Until there is increased transparency of meeting attendance, the quality of data cannot improve. This is one area where the CVH innovation of the VotC project can immediately improve practice as it will streamline the collection of such meeting data thereby yielding more robust estimates. As such, these quality issues are the subject of further research in 2017-2018.

### Audit of ToR

Alongside of the maps of the hierarchy and the interlocks based on links is the importance of the processes of each committee as embedded in their ToR. Of the 323 committees, the results found that just 113 had ToR. In total, 39 (35 percent) were sampled and it was found that they were highly variable in there heading structure (Table I). From these it is evident that none of the committees were reviewed or evaluated, there is no information on how agendas are generated, nor is there information on how the minutes are processed. These are key issues of transparency and accountability that speak to a lack of value given to clinicians’ issues, and the lack of feedback to clinicians about the resolution of their issues.

### Governance chain analysis

Both the hierarchy and the interlock graphs reveal the complexity of assessing the influence of clinicians’ voice in decision-making structures. Each committee is a number of steps away from the District Governing Board (Figure 1), or the degrees of separation, which is an important measure of social distance and social influence in health research (Valente et al., 2008; Fowler and Christakis, 2008). For example, the District Health Care Quality Committee is one degree from the governing board. In contrast, the Standards Working Party is three degrees removed. Within this complexity, what happens to clinicians’ voice through the steps from one committee to the next, as ideas flow upstream to the governing board? Whether the influence of clinician voice increases the closer a committee is to the governing board will be the focus of the next phase of the VotC project.

Furthermore, a key task of the VotC project is to assess how clinicians’ voice moves from a subordinate committee to a superordinate committee in terms of their issues being “escalated” to committees with higher decision-making authority. Because both the hierarchy link data and the ToR were collected it is possible to assess the diffusion of clinician voice. The principle is that voice should be enabled to flow upstream from subordinate to superordinate committees (see examples provide in Figure 4).

Example 1 in Figure 4 shows that not all committees provided ToR documentation. In contrast, example 2 shows that each committee provided ToR, and thus this alignment can be assessed for how clinicians’ voice travels upstream. The key insight from Figure 4 is that clinicians’ voice travels through many points before – possibly – reaching the governing board. However, whether the frontline clinicians’ voice reaches the governance board cannot be assessed due to the lack of ToR, the absence of minutes from any of the committees, and the absence of any documentation of actions arising from each committee. These pieces are necessary to see if clinicians are given time on the agenda, which should be included in the ToR, to raise frontline issues, if those issues are present in the minutes and whether issues were escalated upstream to the next committee. These quality issues are to be addressed in further work.

In summarizing the key points of the results, the evidence shows that many committees do not, in fact, connect to decision-making structures. Instead, these committees are linked to an artificial “vacuum” which suggests that the voices within the committee may not be heard by organizational decision-makers. However, while some committees may not have had hierarchical links to decision-making structures, all committee members were connected to decision-making structures via the interlocks. This suggests that, even if not directly, clinicians may have influence over decision making through levels of connectedness. Furthermore, there is evidence that connectedness varies greatly across members. Also, and perhaps one result that can yield immediate practical change, was the discovery that only 35 percent of the committees even had ToR. The lack of ToR documentation suggests that such committees may be susceptible to inefficient feedback loops wherein the clinician’s concerns may not have been passed upward to decision-makers nor may they hear about the resolution of their original concerns.

## Unresolved questions and lessons for the field

The VotC project, to date, has exceeded expectations and been received with much optimism with work to continue in 2017-2018. The purpose of the first year (2016) was to determine and describe the structural location of clinicians’ voice in organizational decision-making processes in a health system in Australia. The project provided a baseline illustration of the current committee activity and impediments to the VotC not being heard by those in decision-making power in the organization. In that way, the project has been quite successful.

One of the more prominent future opportunities involves further exploration into whether restructuring the linkages – like restructuring road networks – results in more effective communication of clinician issues to executive decision-makers. Moving forward, the next phase of the VotC project will include a committee audit, review and redesign strategy: an audit of all committee charters/ToR (American Hospital Association, 2008), the collection of interview and survey data that further captures the clinician perspective, statistical modeling of social network metrics with clinician engagement survey response, and further develop the CVH technology. Additionally, the CVH technology will be implemented on a larger scale that traverses well beyond the borders of the MNCLHD system. Lastly, the project will be replicated in a different cultural setting and one with a structurally dissimilar health system, namely, the USA.

Finally, translating this project into practice involves deploying the CVH on a centralized computer system in combination with an education and training program. The transferability and scalability are underpinned by a committee system common to all local health districts using the same database variables, centralized server, and web-based interface, further permitting individual log into an engaging and interactive committee network map. By drawing on the perspectives of system-wide communication, individual clinician voice in the system, team-level information, and network influence, the VotC project and CVH innovation explicitly capture committee purpose which empowers clinicians’ voice and enables the further observation of their input creating organizational change. This outcome directly tackles the concerns shared by Cohn (2015) and Sears (2011) who identified listening to clinician perspective and implementing it into decision making as tied to engagement. In conclusion, through the VotC project and CVH, clinicians will be able to see all organizational committees and how they are linked into the formal hierarchical structure of the system. With implementation, the CVH unlocks the potential for clinicians to communicate clinical issues to other committees, visibly see their voice (and other clinician voices) in the system through the committee interlock, observe their committees in the system with the ability to access and edit information, and witness how influence can be leveraged through networked governance.

## Figures

#### Figure 1

Hierarchical governance structure visualization of committees within the MNCLHD

#### Figure 2

Committee interlock graph for the MNCLHD

#### Figure 3

Detailed view of the center of the MNCLHD committee interlock graph

#### Figure 4

Two examples of committee reporting structures

## Table I

Sections of terms of reference

Membership/Orientation 39 100
Title 35 90
Purpose 32 82
Terms of Reference 29 74
Quorum 27 69
Objectives 25 64
Meeting Frequency 25 64
Reporting/Delegations 25 64
Agenda/Minutes/Meeting Papers 25 64
Chairperson 22 56
Evaluation & Review 21 54
Authority 20 51
Secretariat/Support 17 44
Meeting Procedures 13 33
Meeting Time/Venue 12 31
Membership Variables/Alternate 9 23
Signature/Authorisation 9 23
Role 7 18
Standing Items 7 18
Responsibility 3 8
Venue 3 8
Invitees 3 8
Meeting Duration 3 8
Accountability 3 8
Reports for Tabling 3 8
Background 2 5
Introduction 2 5
Voting Rights 2 5
Co-chair responsibilities 2 5
Minutes 2 5
Conflict of Interest 2 5

Notes: The following headings had one reference each and represented 3 percent of the total, respectively: “aim,” “program,” “strategic context,” “guiding principles,” “key performance indicators,” “roles and responsibilities of committee members,” “funding,” “appointment of co-chairs,” “scope of representation,” “decision making,” “working groups,” “apologies,” “linkages,” “budget,” “sub-working groups,” “stakeholders,” “confidentiality,” and “media”

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## Acknowledgements

This case study was funded by Dr Lock’s Australian Research Council Discovery Indigenous Grant No. IN140100031.

## Corresponding author

Mark J. Lock can be contacted at: marklock@committix.com.au