Leadership and Management CMT 201011

 

Leadership and Management The Present & The Future th CMT 20 October 2011

Dr Robert Ghosh CD, CUC Chair, CE

 

Segment 1. General Principles

 

Why Now? • Everyone is talking about it • Modern phenomenon? • Old values • Not only are we living in more enlightened, egalitarian times where simple assumption of authority and power by way of ‘status’ does not wash, but those of us with ‘status’ are also driven by external forces such as targets.

 

Definitions • Social influence (Marx)  (Marx)  • Roman Catholic Diocese of Rochester

: "the process of influencing  influencing the the behaviour of other people toward group goals in a way that fully respects their freedom." • Everyone can lead

 

Particulars • • • •

• • •

• •

Definitions for all healthcare workers  workers  Any actions which aid influence  influence for for the benefit of patients, the staff and the institution Cross boundaries (have the ability to influence  influence those those outside your profession and area of work) Influence those Influence  those you report to, your peers and those who report to you Particular skills for medical students and trainees  Actions which may respectfully and professionally demonstrate potential improvements or adjustments to ways of working Actions which may respectfully and professionally demonstrate concern or displeasure at ways of working Particular skills for Consultants  Actions which may demonstrate influence  influence through through authority, despite modernisation issues such as minimal variation of practice and mandatory targets

 

Management • Lati Latin: n: ma manu nu ag ager ere e ““to to lead lead by the the han hand” d”  • Old Fren French ch:: ména ménage geme ment nt “the “the art art of cond conduc ucti ting ng,, directing”  • „The „The a act, ct, manner manner,, or or prac practic tice e of of m mana anagin ging; g; hand handlin ling, g, supervision, or control‟ (Online dictionary)  • the skilful or resourceful use of materials, time, etc. (Online dictionary) • FACILITATION • TAKING ON A BURDEN (not dependent on ability) • Specific knowledge: awareness of networks and landscape • INFLUENCE  – LEADERSHIP!

 

Doctors as managers • Con: history • Pro: medical knowledge; engagement of

other doctors

 

Drivers for Management and Leadership  • „M „Man anag agem emen entt Cours Course‟ e‟:: this this is us usua ualllly ya an n appraisal prerequisite in the penultimate year in ARCP and RITA • High profile programmes within medical education curricula, strategic health authorities and various other bodies • Le Lead aders ershi hip p de deve velo lopme pment nt con consi side dere red d „a g goo ood d thing‟ for the reasons identified in segment 1 (definition and rationale) • Seen increasingly as career progression

 

Standards and targets  targets  •

• •

Most Most woul would d agree agree that that any any indiv individu idual al can can „tell „tell people people to do do thing things‟ s‟ and „point them towards standards‟.  Leaders engage, enthuse and enlighten with regard to goals. To maximise engagement, ensure complete awareness of:  – Reasons for conception of the target or standard by responsible body (e.g. DoH, SHA) and their methodology for consultation and implementation  – How the responsible body ensures compliance from the Trust and the nature of any additional monitoring bodies  – The Trust response: complete rejection, partial acceptance, complete acceptance and reasons for this  – Commissioning views  – Trust Governor views divisions/directorates  – The role of committees and divisions/directorates  – The role of the Department and the role of the individual; risks of rejection of the goal/task/standard/target; ways of innovating to implement

 

Motivation • Targets will not be reached if the workforce are unhappy, unmotivated and

not engaged • Leaders need to praise their staff (even if on occasions this does not seem justified) and advertise their value to the Trust

 

Transaction • Motivated, happy individuals will need direction for goals and standards • Transactional approaches include incentivisation and punishment

 

Segment 2: Landscape

 

History • • • • • • • • • • • •

The Griffiths Report – the introduction of general management, 1983 Working for patients, 1989 (‘the internal market’)  National Service Frameworks: 1998 NHS Direct: 1998 European Working Time Directive (EWTD): 1998 Measuring standards: 1999 (also 2004 and 2008) – CHI 1999; HCC 2004, CQC 2008 NICE: 1999 The NHS Plan: A plan for investment, a plan for reform, 2000 Adverse healthcare events: An Organisation Organisati on with a Memory Memory,, 200 2000 0  Kennedy report: 2001 Payment by results, and some other particulars with regard to finance: 2002 Hospital at Night (HAN): 2004

•• • • • •

Modernising Medical Careers (MMC): 2005 Ara Darzi reports: 2006 Best Research for Best Health (BRBH): 2006 ‘Tooke’ report: ‘Aspiring to Excellence’: 2008   The Francis Report: February 2010 The White Paper. Equity and Excellence: Liberating the NHS. July 2010.

 

National structure Houses of Parliament 

Primary care: GP, NHS Direct, walk-in,

Department of Health including Secretary of State  Independent Regulator for NHS Foundation Trusts 

dentists, opticians, pharmacists 

Strategic Health Authorities  Primary NHS Trusts includin including: g: Acute and Foundation Trusts Mental and Ambulance Trusts

Non NHS Organisations E.g. private hospitals 

Care  Trusts 

 

National structure • DoH including Board • SHA • Commissioners • Acute and Foundation Trusts

 

Local structure Trust Board including Executive Board

Clinical Board

Divisions (amalgamation of directorates)

Corporate committees and units

Directorates (amalgamation of service lines)

Service line units: a clinical or operational oper ational unit which may manage itself with regard to quality and finance. In larger Trusts, an example may be „colo -rectal surgery‟. In smaller  Trusts, „surgery‟ may form a service line  

 

Local structure • Trust Board • Executive Board • Clinical Board • Middle tiers • Depa Depart rtme ment nt („se („serv rvic ice e lin line e uni unit‟ t‟))  • Service line reporting and management (SLR and SLM)

 

Governance and Quality • Now the same thing • Pillars were out • Now back in (projects)

 

Quality Projects • Patient experience and complaints • Patient safety: Morbidity & mortality, risk

management and infection control • Research • Finance including PBR and CQUINS • development, Staff – concerns, medical education, revalidation, appraisal, continuing performance (including job planning) • Clinical effectiveness including clinical audit

 

Other skills • Legal and ethical: MCA 2005, limitations of care • Data handling

 

Segment 3: Theories of Leadership

 

Some examples • Trait theories: Individuals born into leadership and could only be inherited –  hugely discredited • Path-goal and transactional • Charismatic • Nearby • Synergistic approach – vertical (transactional) (transaction al) versus horizontal (motivational)

 

Other issues • Control and power: may be lost in large organisations • Emotional intelligence: this is based on the concept of the ability of leaders and managers to understand and manage their

emotions and relationships (empathy, pragmatism)

 

Motivation • • • • • • • • • •

Vision  Vision  Passion though may be misdirected Trust - difficult, transparency. The following is not consistent with trust: hidden agendas; inconsistent standards; misplaced benevolence towards erratic individuals; false feedback when the truth would have been better; rumour/gossip Stability.. Stability Able to follow when required and able to listen Power:: power identity or power reputation. Power Positive issues should be found in adversity and failure put into perspective and learnt from Perseverance One needs to establish the definition of looking down, looking sideways and looking up. Particularly for doctors, the difference between authority and arrogance needs to be established.

 

Change management •

A. Pattern of change (reference: Elizabeth Kubler-Ross, initially described  for bereavement): bereavement):  – Action points for Denial (including shock) Stage • Give information • Confirm the change will  will happen happen • Explain what to expect and how to adjust

 – Action points for Resistance Stage • Listen, empathise and respond to concerns • Remind of reality • Expect falling productivity

 – Acceptance of reality  – Action points for Commitment Stage • Set long term goals • Team-building, reward and celebrate • Look forward

 – Action points for Exploration Stage • Prioritise/focus with with short and long term goals • Follow up • Reward

 

Change management • B. Stages of engagement    – Innovators (2.5%)  – Early adopters (13.5%): do not need evidence  – Early majority (34%): need evidence  – Late majority (34%): go with the flow  – Laggards (16%): get there eventually  – START WITH INNOVATORS/ EARLY ADOPTERS

 

Change management •

C. General principles in managing change    –  –  –  –

Description of background and urgency Creation and communication of vision Emphasis of the benefits/risks of change versus no change Identification of all stakeholders

 –  –  –  –

Analysis of those who will lose l ose out Discussion with individuals personally Identification and formation of working group Clarity with regard to changes in behaviour an attitude. Things to start/stop doing and things to do more/less of Facilitation of change. Removal of obstacles and encouragement of innovation. Utilisation of education tools and operational processes Development of regular update meetings Development of reward system and encouragement; adoption of model behaviour into institutional behaviour Design of temporary systems for neutral (transition) zone (e.g. temporary procedures/policies); utilisation of this period to identify innovation

 –  –  –  –

 

Medical Leadership Competency Framework (Becoming better known as NHS Leadership •

•

The Academy of MedicalFramework) Royal Colleges, together with the NHS Institute for Innovation and Improvement published their own „take‟ on clinical leadership in 2009 - a competency framework based on the concept of „shared leadership‟* . There is an expectation and widespread agreement that the framework will be embedded in education and training curricula at allw stages the UK. Dentistry will no doubt follow follo suit. of medical education in The MLCF is not intended to be prescriptive, or indeed the final word on leadership, but it does provide us with a language with which to converse about leadership and a common sense of purpose in constructing training programmes programmes or development development opportunities. opportunities. All clinical leadership development activity in the London Deanery will be mapped onto this framework.

 

Demonstrating personal qualities •

Developing self-awareness  self-awareness   –  –

•

Managing yourself  yourself   –  –  –

•

Time management Clinical skills; innovations for acquisition Managerial skills e.g. organising meetings, chairing meetings, implementing change; consultants should identify issues which may be dealt with by SPAs, particularly „mandatory‟ items such as training (supervision) and clinical governance (quality); trainees should identify non-clinical issues which need attention e.g. clinical audit  audit 

Continuing personal development  development   –

•

Interface with colleagues, patients/relatives, managers. Multi-source feedbacks; ask people!  people! 

Seek opportunities; opportunities; think of forums other other than „formal „formal CPDs‟; CPDs‟; acknowledge mistakes 

Acting with integrity  integrity   –  –  –

Awareness of acting: providing dignity to a colleague who may be experiencing difficulties SCENARIO 1: Pre-retirement colleague who may be making clinical mistakes, has not accumulated CPD SCENARIO 2: Junior doctor (recently bereaved) is consistently arriving late for clinical duties

 

Working with others •

Developing networks  networks   – Immediate network: Individuals or groups who may have differing opinions about common issues affecting the department/specialty.  – Wider network: Individuals or groups who may benefit from knowing about the department/specialty problems, or who may be able to influence  – personnel Identify networks and ways ways of of working c ommunicating communicating managers and medical to arrange e.g. for covering ce.g. overing annual/sick leave leave  

•

Building and Maintaining Relationships  Relationships   – Ensure that there is empathy from each group for each other  other 

•

Encouraging Contribution  Contribution   – Identify expertise in different individuals in each clinical and non-clinical situation  – Designate roles for these individuals  individuals  

•

Working within Teams  Teams   – Aims: common purpose, leadership, roles and responsibilities of all individuals i ndividuals  – Identify all clinical situations si tuations when you can employ the principles above

 

Managing Services •

Planning   Planning

 –

Identify benefits and risks of plans, organise trackers to identify hurdles and identify resources if needed Ensure that there is measurable quality assurance to ensure that plans will lead to improved quality Ensure audit to maintain quality

 –

Draw up awhich plan maps to dealtowith ofpoints your major anxieties and organise a checklist the one bullet above  abovedepartmental  

 –  –

•

Managing resources for the plan above  above   –  –  –  –

• •

Identify the resources (manpower and equipment) in your department/specialty to ensure service delivery Devise a way of detecting when service not delivered Devise a way of detecting when resources not used effectively Develop a portfolio of service delivery issues and ways of detecting service and resource problems   problems

Managing people: synergistic approach Managing performance and tackling difficult issues  issues   –  –  –

Analyse information about performance (department and individual) and act to improve performance SCENARIO 1 : The department is failing in a „target‟  SCENARIO 2: A colleague is ignoring managerial issues

 

Improving services •

Ensuring patient safety  –  –  –  –

•

Identify and quantify the risk to patients Use evidence to identify options to minimise risk Monitor the effects and outcomes of change SCENARIO: SCENA RIO: consider an intervention e.g. admission, ward rounds, discharges; devise a way of measuring the outcome on patient safety

Critically evaluating the interventions above

 – Devise quality checks for the interventions Analyse se quality checks in real time and through audit  – Analy

•

Encouraging improvement and innovation for the interventions above  – Question the status quo  – Act as an exemplar for innovation  – Analy Analyse se educational ttools ools and operational processes

•

Facilitating transformation for the interventions above  – Articulate, promote, motivate and focus a group to accomplish change  – Identify your role; identify groups and forums to facilitate change

 

Setting direction (strategy) •

Identifying the contexts for change  – Demonstrate awareness of the political landscape (understand and interpret relevant legislation and accountability frameworks e.g. external visitations for standards, quality indicators)  – Prepare for the future by scanning for ideas and best practice that will impact on health outcomes  – Develop and communicate aspirations  – Identify ways of communicating ideas; be involved in strategy meetings at departmental/divisional/directorate/ trust level

•

Applying knowledge and evidence to support such change  – Gather data in order to challenge existing practices and influence others in appropriate forums; communicate as above

•

Making decisions

•

Evaluating impact of implemented ideas

 – Participate in/ contribute to organisational decision-making processes; involve key people who make decisions; seek delegated responsibility

 – Test/evaluate new service options using measurable criteria; overcome barriers to implementation with education tools/ process changes

 

Summary • Know why • Landscape: history and structure • Governance and quality: projects • Basic theories to help deliver