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Leadership and ManagementThe Present & The FutureCMT 20th October 2011
Dr Robert Ghosh
CD, CUCChair, CE
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Segment 1. General Principles
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Why Now?
Everyone is talking about it
Modern phenomenon?
Old values
Not only are we living in more enlightened,egalitarian times where simple assumption ofauthority and power by way of status does
not wash, but those of us with status arealso driven by external forces such astargets.
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Definitions
Social influence (Marx)
Roman Catholic Diocese of Rochester: "the process of influencingthe behaviourof other people toward group goals in away that fully respects their freedom."
Everyone can lead
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Management
Latin: manu agere to lead by the hand Old French: mnagement the art of conducting,
directing The act, manner, or practice of managing; handling,
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 andlandscape
INFLUENCE LEADERSHIP!
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Doctors as managers
Con: history
Pro: medical knowledge; engagement ofother doctors
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Drivers for Management andLeadership
Management Course: this is usually anappraisal prerequisite in the penultimate year inARCP and RITA
High profile programmes within medicaleducation curricula, strategic health authoritiesand various other bodies
Leadership development considered a good
thing for the reasons identified in segment 1(definition and rationale)
Seen increasingly as career progression
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Standards and targets
Most would agree that any individual can tell people to do thingsand 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 andimplementation 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 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 toimplement
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Motivation
Targets will not be reached if theworkforce are unhappy, unmotivated andnot engaged
Leaders need to praise their staff (even ifon occasions this does not seem justified)and advertise their value to the Trust
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Transaction
Motivated, happy individuals will needdirection for goals and standards
Transactional approaches includeincentivisation and punishment
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Segment 2: Landscape
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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 with a Memory, 2000 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.
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National structure
Houses of Parliament
Strategic Health Authorities
NHS Trusts including:
Acute and Foundation Trusts
Mental and Ambulance Trusts
Non NHS
Organisations
E.g. private hospitals
Independent
Regulator for
NHS FoundationTrusts
Department of Health
including Secretary of State
Primary
CareTrusts
Primary care:
GP, NHS Direct, walk-in,
dentists, opticians,
pharmacists
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Local structure
Trust Board
Executive Board
Clinical Board Middle tiers
Department (service line unit)
Service line reporting and management(SLR and SLM)
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Governance and Quality
Now the same thing
Pillars were out
Now back in (projects)
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Quality Projects
Patient experience and complaints
Patient safety: Morbidity & mortality, riskmanagement and infection control
Research
Finance including PBR and CQUINS
Staff concerns, medical education, continuing
development, revalidation, appraisal,performance (including job planning)
Clinical effectiveness including clinical audit
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Other skills
Legal and ethical: MCA 2005, limitations ofcare
Data handling
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Segment 3: Theories of Leadership
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Some examples
Trait theories: Individuals born intoleadership and could only be inheritedhugely discredited
Path-goal and transactional Charismatic
Nearby
Synergistic approach vertical(transactional) versus horizontal(motivational)
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Other issues
Control and power: may be lost in largeorganisations
Emotional intelligence: this is based on theconcept of the ability of leaders andmanagers to understand and manage theiremotions and relationships (empathy,
pragmatism)
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Motivation
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; falsefeedback when the truth would have been better; rumour/gossip
Stability. Able to follow when required and able to listen Power: power identity or power reputation. 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, lookingsideways and looking up. Particularly for doctors, the differencebetween authority and arrogance needs to be established.
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Change management
A. Pattern of change (reference: Elizabeth Kubler-Ross, initially describedfor bereavement): Action points for Denial (including shock) Stage
Give information Confirm the change willhappen 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 short and long term goals Follow up Reward
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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/ EARLYADOPTERS
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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 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 modelbehaviour into institutional behaviour Design of temporary systems for neutral (transition) zone (e.g. temporary
procedures/policies); utilisation of this period to identify innovation
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Medical Leadership Competency Framework(Becoming better known as NHS Leadership
Framework)
The Academy of Medical Royal Colleges, together with the NHSInstitute for Innovation and Improvement published their own takeon clinical leadership in 2009 - a competency framework based onthe concept of shared leadership* . There is an expectation andwidespread agreement that the framework will be embedded ineducation and training curricula at all stages of medical education in
the UK. Dentistry will no doubt follow suit.
The MLCF is not intended to be prescriptive, or indeed the final wordon leadership, but it does provide us with a language with which toconverse about leadership and a common sense of purpose inconstructing training programmes or development opportunities. All
clinical leadership development activity in the London Deanery willbe mapped onto this framework.
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Demonstrating personal qualities
Developing self-awareness Interface with colleagues, patients/relatives, managers. Multi-source feedbacks; ask people!
Managing 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 mandatoryitems such as training (supervision) and clinical governance (quality); trainees should identifynon-clinical issues which need attention e.g. clinical audit
Continuing personal development Seek opportunities; think of forums other than formal CPDs; acknowledge mistakes
Acting with 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
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Working with others
Developing 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 Identify networks and ways of communicating e.g. managers and medical
personnel to arrange ways of working e.g. for covering annual/sick leave
Building and Maintaining Relationships Ensure that there is empathy from each group for each other
Encouraging Contribution Identify expertise in different individuals in each clinical and non-clinical situation Designate roles for these individuals
Working within Teams
Aims: common purpose, leadership, roles and responsibilities of all individuals Identify all clinical situations when you can employ the principles above
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Managing Services
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 a plan to deal with one of your major departmental anxieties and organise a
checklist which maps to the bullet points above
Managing resources for the plan 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
Managing people: synergistic approach Managing performance and tackling difficult 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
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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: 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 quality checks in real time and through audit
Encouraging improvement and innovation for the interventions above Question the status quo Act as an exemplar for innovation Analyse educational tools 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
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Setting direction (strategy)
Identifying the contexts for change Demonstrate awareness of the political landscape (understand and
interpret relevant legislation and accountability frameworks e.g. externalvisitations for standards, quality indicators)
Prepare for the future by scanning for ideas and best practice that willimpact on health outcomes
Develop and communicate aspirations
Identify ways of communicating ideas; be involved in strategy meetings atdepartmental/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 Participate in/ contribute to organisational decision-making processes;
involve key people who make decisions; seek delegated responsibility Evaluating impact of implemented ideas
Test/evaluate new service options using measurable criteria; overcomebarriers to implementation with education tools/ process changes
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Summary
Know why
Landscape: history and structure
Governance and quality: projects Basic theories to help deliver