Performance Management ver 2.ppt

Health and

Everything

Performance Management

InsightSeptember 27, 2006

The Old Mill

Health and Everything

Notes

• No need to take notesThis presentation and a lot more material is on these issues is available on our web sitewww.healthandeverything.orgFor more information you can write to me [email protected]


The NHS • The Blair government created

strategic health authorities (SHAs) in 2002 specifically to performance manage the newly created primary care trusts (PCTs).

• There was thus a four year experiment with a large scale performance management effort worth looking at.


Performance Management NHS 2002-2005

Minister of Health

Department of health

28 StrategicHealth

Authorities

180 Acute and Mental Health Trusts 200 Primary Care Trusts

1.000.0000 Employees


My Role • I have been meeting semi-annually with a

representative cross section of the NHS from 1990 to review the state of play and changes that have occurred

• I consulted to a strategic health authority from 2001 to 2005 – I met with them 4 times a year to see how they

were doing and lend a hand in their efforts.• I also consulted to a Primary Care Trust

from 2001 to 2003– I met with them 5 times and helped with their

planning efforts


Introducing Performance Management in the UK

• A specific publication on performance management was prepared in 2002, but is no longer available on the internet or in hard copy

• So I have used standard sources to give an overview of Performance Management

• Various Outlines and Reports are available that helped to describe how it was implemented in the NHS


Performance managementPerformance management is the systematic process by which an organization involves its employees, as individuals and members of a group, in improving organizational effectiveness in the accomplishment of its mission and goals.


Employee performance management includes:

• Planning work and setting expectations, • Continually monitoring performance, • Developing the capacity to perform, • Periodically rating performance in a summary

fashion, • Rewarding good performance. Planning Monitoring

Rewarding

Rating

Developing


Employee performance management includes:

Planning Monitoring

Rewarding

Rating

Developing


Planning• Set performance expectations and goals• Involve employees in the planning process

– help them understand goals (what why and how)• Establish elements and standards of

performance appraisal– that are measurable, understandable, verifiable,

equitable & achievable. • Hold employees accountable as individuals• Plans should be flexible• Plans should be discussed often and not

seen only when formal ratings are required.

Planning


Planning in the NHS: Trust Involvement

• Introduction of 3 year Local Delivery Plans to be prepared by individual trusts– Bottom up planning to involve all

local agencies with support from the SHA

– Stabilization of planning and funding over 3 year periods

Planning


Monitoring• Monitor continually. • Consistently measure performance• Provide ongoing feedback on

progress toward goals.• Compare performance against their

elements and standards. • Change unrealistic or problematic

standards • Identify and correct unacceptable

performance quickly

Monitoring


Monitoring in the NHS• Three Major agencies to monitor and

assess the system• NICE: National Institute for Clinical

Excellence– To review standards and improve clinical

practice • CHI: Commission for Health

Improvement– To consider impact on health of the nation

• Audit Commission– To monitor and assess fonancial and

operational management

Monitoring


Developing• During planning and monitoring of work

– Deficiencies become evident and can be addressed– Successful employees can be helped to further improve

• Evaluate and address developmental needs• Increasing capacity to perform through training, • Give assignments to introduce new skills or

higher levels of responsibility, • Improve work processes• The above encourage good performance

– Strengthen job-related skills– Help employees keep up with changes in the workplace

Developing


Developing in the NHSCreation of the “Modernization Agency”

– Seconded the best development officers– To help define the shape of the “New and

modern NHS”– Then to identify and develop the new skills

and competencies needed for the new NHS– To identify and deal with development

issues quickly

Developing


Rating• Organizations need to know who their best performers

are.

• Rating allows you to compare performance over time or among various employees.

• Evaluates employee or group performance against the elements and standards

• Assigns a summary rating of record for each employee. – based on work performed during an entire appraisal period. – has a bearing on various other personnel actions

• granting within-grade pay increases • determining additional retention service credit in a reduction in force.

Rating


Rating in the NHS• An Annual Report on the performance

of individual organizations– Linked to the measurable targets– Uses a three star rating system

• 0 stars = poor• to 3 stars: excellent

• Individual Managers and organizations are rated using these performance measures at every level of the system

Rating


Rating in the NHS: 45 Measurable Targets

Key target

A&E emergency admission waits (12 hours)

Cancelled operations not admitted within 28 days

Financial management

Hospital cleanliness

Improving Working Lives

Number of inpatients waiting longer than the standard

Number of outpatients waiting longer than the standard

Total time in A&E

Two week cancer waits

Capacity and capability

Consultant appraisal

Data quality

Fire, Health & Safety

Information Governance

Junior doctors' hours

Sickness absence rate

Staff opinion survey

Clinical focus

Clinical Negligence

Deaths within 30 days of a heart bypass operation

Deaths within 30 days of selected surgical procedures

Emergency readmission to hospital following discharge

Emergency readmission to hospital following discharge for children

Emergency readmission to hospital following treatment for a fractured hip

Emergency readmission to hospital following treatment for a stroke

Infection control procedures

Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia improvement score

Thrombolysis treatment time

Patient focus

A&E emergency admission waits (4 hours)

Better hospital food

Breast cancer treatment

Cancelled operations

Day case booking

Delayed transfers of care

Nine month heart operation waits

Outpatient A&E survey - access & waiting

Outpatient A&E survey - better information, more choice

Outpatient A&E survey - building relationships

Outpatient A&E survey - clean, comfortable, friendly place to be

Outpatient A&E survey - safe, high quality, co-ordinated care

Paediatric outpatient did not attend rates

Patient complaints procedure

Privacy & dignity

Six month inpatient waits

Thirteen week outpatient waits

Total inpatient waits

Waiting times for Rapid Access Chest Pain Clinic

Planning

http://www.chi.nhs.uk/Ratings/Trust/Indicator/indicatorDescriptionShort.asp?indicatorId=1001
















































Rewarding• Recognize employees, individually and as

members of groups, • Acknowledge contributions to the mission• All behavior is controlled by its

consequences– formal and informal– positive and negative.

• Informal recognition is constant and ongoing like saying "Thank you“

• More formal rewards include cash, time off, and many non-monetary items.

Rewarding


Rewarding in the NHS• The main group reward in the NHS is

through the creation of Foundation Trusts• Individual organizations that have far

more independence and can increase their local rather than national reporting relationships

• This is replicated inside SHAs and indeed inside the existing trusts– Successful managers move up quickly– A successful CEO of an SHA received a

knighthood

Rewarding


2006 • In 2006 the Ministry of Health

reduced the number of strategic health authorities to 14 and radically changed the primary care trusts.

• They merged the monitoring agencies• Performance Management is no

longer the flavour of the month• How did it all go so wrong? Not that

anyone admits it.


Planning in the NHS: Trust Involvement

• The 3 year Local Delivery Plans (LDPs) took two years to frame– Local trusts did not perform well– The SHAs believed that they did not have the planning

capacity to prepare the extensive documentation. • LDPs were renewed annually• LDPs were required top down and the bottom up was to

get them done in an acceptable way• Annual revisions reduced the stability that was

expected• The SHAs could not performance manage trusts

adequately and were therefore largely merged into larger less directive organizations

• What would bottom up planning be in the NHS?

Planning


Planning in the NHS: Targets

• The priority targets were largely met or fudged.– Some incidents of faking data– Some incidents of meeting stated targets but

subverting the real meaning– Widespread hidden overspend

• Government boasted of success in reducing all waiting times

• Head of NHS was fired for £1Billion accumulated deficit that emerged suddenly

• What does measurable really mean?

Planning


Monitoring in the NHS• Three Major agencies to monitor and assess

the system disagreed about the state of individual trusts that they examined

• They functioned as largely independent and somewhat competing inspectorates

• They disagreed about what the standards meant

• They also overloaded individual trusts with monitoring demands

• They were merged into one organization that is now much more hierarchically connected to the Ministry.

Monitoring


Developing in the NHS

• The Modernization Agency was disbanded in 2005– (The government declared it to be a success and closed it

down)• The best development officers had been stripped

from local organizations and now would not go back• The performance management of development issues

was largely done through punitive measures at the SHA rather than the Modernization Agency. – Many executive level managers of trusts lost their jobs.

• The failure to perform “old skills” like those associated with budget management was widespread

Developing


Rating in the NHS• The Annual Report was awaited with bated

breath because your job depended on it– Linked to the priority targets so other non-

targeted areas suffered– Targets continue to be attacked constantly– The three star rating system had its downside

• 0 stars pretty much meant that at least the CEO was fired

• 3 stars meant that you became high profile• Individual Managers and organizations are

rated using these performance measures at every level of the system

Rating


Rating in the NHS


Rating in the NHSKey targets •A&E emergency admission waits (12 hours) •Cancelled operations not admitted within 28 days •Financial management •Hospital cleanliness•Improving Working Lives •Number of inpatients waiting longer than the standard •Number of outpatients waiting longer than the standard •Total time in A&E •Two week cancer waits


Rewarding in the NHS• The main reward in the NHS is through the

creation of Foundation Trusts– There is a serious question about how these

organizations link to the rest of the NHS– This has consequence to everything from funding

flow to patient flow.• Individual organizations that have far more

independence and can increase their local rather than national reporting relationships

• There is much talk about the future of these organizations

• Punishment for failure seems more in the air motivator than reward for success

• The knighted head of the NHS Sir Nigel Crisp lost his job over these efforts

Rewarding


The Law of Unintended Consequences

• With all good intentions this massive effort to implement performance management failed

• Does this mean that performance management will go the way of other similar management ideas?

• Why did it fail? Can it be recuperated? Or should it simply cross the ocean to be implemented in Ontario?

• I have some closing thoughts


Following a Recipe A Rocket to the Moon Raising a Child

• Formulae are critical and necessary

• Sending one rocket increases assurance that next will be ok

• High level of expertise in many specialized fields + coordination

• Rockets similar in critical ways

• Relative certainty of outcome

• Optimism re results

• Formulae have only a limited application

• Raising one child gives no assurance of success with the next

• Expertise can help but is not sufficient

• Every child is unique

• Uncertainty of outcome remains


Complicated Complex

• The recipe is essential

• Recipes are tested to assure replicability of later efforts

• No particular expertise; knowing how to cook increases success

• Recipes produce standard products

• Certainty of same results every time


Simple


Analysis• Health care organizations and systems

are complex• Recipes won’t work and their application

will have unintended consequences• Performance management like many

other flavours of the month can be useful but should be applied with great care and foreboding while carefully considering the complexity of local conditions

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Performance Management ver 2.ppt

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