Standardised Management Conversation

The Book

I have written a mini-ebook called Standardised ManagementConversation (SMC) which I think is essential for healthcare directors, managers and senior clinicians. The SMC is a model which is to be used when various healthcare managers talk to those who report to them. It will also be useful for non-healthcare professionals and managers as the fundamental principles are more or less the same.

Since the conversation is standardised in the model, it makes conversation between people predictable and stable with no surprises. The model is based on sound principles, years of observations and practical experience. It draws on conventional management, clinical ‘lean’ management and some lateral thinking.

It is a small booklet. It is priced at £0.99 for UK and $0.99 for USA (equivalent prices for other countries) published in the ebook format via Amazon available at this link http://www.amazon.co.uk/gp/product/B018AWBJTU

The Cause

I will be donating all the money that I get from the first year (November 2015 to December 2016) sales of this mini-ebook to a charity called Udavum Karangal in India ( http://www.udavumkarangal.org/  ) for the purpose of sponsoring an orphan child all the way through childhood till the child finishes education and leaves the orphanage. This scheme costs about $1000 or £600 which is actually a great value for money to see a child through childhood and education, thus providing a solid foundation for a stable adult life. I like long term thinking and long term benefits, that is why I have chosen this charity. I have personal experience of sponsoring children through this scheme. I have no other relationship with this charity, they do not know that I am doing this.

So here we go, if you are a director or manager in any field or have aspirations to become one in the future, especially if you are in healthcare, if you are a clinician with an interest in management, buy the mini-ebook SMC - Standardised Management Conversation. If you like it and use it and you are successful it is a win for you as a reader of SMC booklet, it is a success for me as an author and it is a success for a child till he/she becomes an adult. Well, if you do not like it, your £0.99 is pure charity.

It is a win-win-win whichever way you look at it. You may perhaps now want to make a guess on the gist of the content of the SMC mini-ebook.

Thank you for your support.

©M HEMADRI

Follow me on Twitter @HemadriTweets

PS: As a new author, new to e-publishing, if there are issues with it kindly provide me feedback so that I can improve on it.

Power words to avoid in healthcare

On words such as 'intelligence', 'insight' and 'discretion' used as tools in demonstrating power.........................

A colleague had an email from a clinical director asking to ‘acknowledge that CT Cologram is a scarce resource to be used intelligently’.

When we got talking about this we wondered how one was supposed to respond, react or put this into action. What did that mean? Does it mean that they as a department they were using the resource like a bunch of idiots? Is this saying that they were a part of a group of people with not such a high intelligence? They were talking about doctors most of whom had at least two degrees and many years of training and experience - generally thought of as abundant proof of intelligence.

You can see this has raised my hackles. What is really interesting is this comes from a hospital which had one of the highest utilisation of CT scans in the country. If they were abusing CT facilities already, why would a cologram (colonography) be an exception? 

The issue is not the CT use intelligent or otherwise. The issue is the lack of understanding of how clinical management works and the use of operational management language. It is the lack of analysis and lack of definition behind these statements that are the problem. Of course no manager who imagines he/she is worth his/her salt will ever agree that this type of communication is grossly deficient. In fact the managers will insist that ‘intelligent use of resources’ is essential. And they can prove it. They will prove it by letting others use the resource and then using their higher hierarchical authority by making a post-event, ad hoc individual judgement on others who used the resource intelligently. You can see how it massages the ego of individual managers and riles up everyone else.

There are many other terms which lack analysis or definition yet used very liberally by everyone. Insight is one. Discretion is another.

Many doctors in trouble are accused of lack of insight. A GMC related official described insight as breathtaking arrogance in the face of overwhelming evidence.....  So, it is safe to assume that when evidence is presented to a doctor that he/she is no good and yet the doctor maintains that he/she was good would probably classed as lack of insight. At this point, it may look acceptable.

The point is, the use of ‘lack of insight’ as a reason and sanctions that follow often comes from a people with higher authority and directed against people with lower authority. In medical practice there is none or very little evidence for many things we do. In such a situation evidence becomes the view of a group of people in power who are then not inclined to look at the evidence presented by the weaker party. Insight becomes a power game. 

Let us look at discretion. Let us say that your boss in clinical medicine says that all patients are not the same and you must use your discretion according to the given situation. You are likely to think that your boss has given you a lot of freedom. What you are actually being set up for is another power game where your boss retains the right to question your discretion, pitch your discretion with others discretion and to override your discretion. Now you might think that is why you have bosses. But what actually happens is a clear recipe for failure and conflict. 

There are better ways of dealing with these. At a simple level as a starting point is to stop using such words which have the potential to confuse and cause harm; words such as discretion, insight and intelligence in day to day operational activity. I am not saying these words or their implications are not important, of course they are; I am questioning if they should be used in day to day operational management especially in healthcare. 

Instead clear definitions agreed as a group, in the form of specific and detailed protocols with further second and third order protocols defined when the first one does not fit might be a better way in operational management in healthcare. There will be a situation when these definitions will not work in which case a variation made after very quick group consultation which is then analysed later may be needed.

The main issues are that you will not like this since you might feel your autonomy is being reduced; your boss won’t like it since he/she may feel that his/her power is being reduced. Finally the chances are you, your colleagues and your boss will not agree on most things at an operational level; well you see this is not your fault as clinicians are taught only how to make individual decisions implemented according to a power based hierarchical scale. 


Clinicians have never been taught on how agreements are reached and never experienced the power of agreements between them.

There are clear ways to achieve this. That is when you will find Success in Healthcare.

©M HEMADRI

Follow me on Twitter @HemadriTweets

PS: If you would like to get away from the conventional use of terms such as discretion, insight, intelligence and move to a different approach; if you would like to know what agreement actually means and would like help to achieve it – you are welcome to get in touch with me mr.hemadri at gmail dot com

Healthcare has no Red Teams - we need them

NHS has no red teams - we need them

Defence forces have red teams. The US defence has had red teams since the early 2000s, soon the UK defence forces followed with their own version with slight variation. A few private companies such as IBM use red teams.

An internet search did not reveal healthcare especially the NHS using Red Teams.

What is Red Team?

A red team is an 'independent' team within an organisation that is deliberately created by the organisation  to critically analyse from a variety of perspectives (especially from an opponent or competitors perspective) and challenge the organisations' strategies, assumptions, operations  and all other aspects with a view to helping the operational part of the organisation get to a better position.

Basically you hire and pay a team of people to stuff you so that when you get out in the big bad world you don't get stuffed real time.

Red Team is something  but not fully like the opposition in the parliament whose job is to oppose the ruling party yet work for the benefit of the country. The opposition in the parliament provides an alternate view of the issue in question which the government must consider but need not necessarily act upon. A good government would willingly adopt the opposition's ideas if it would benefit the country. Of course given the unsavory political overtones and entrenched positions of political parties these days, this may not be the best example in practice but I think you get the gist. A red team in your organisation is a paid opposition without the baggage of politics - the ability to thoroughly analyse and provide an alternative point of view to the powers that be but no inherent ability to act on their own views.

A Red Team is not................

Red Team is not about providing innovation or offering solutions. Red Teaming is not strategy formulation by the management or organisation. Red Teaming process runs either in parallel to the strategy formulation or immediately after the strategy formulation but before it is finalised, signed off for implementation.

Red Team is not made up of union reps, protestors, resistors, laggards, innovators, management cronies, enthusiasts and so on. Red team is not a group with representatives from any area. Red Teams are not the same as whistle-blowers. They are certainly not people from 'risk', 'clinical governance' or any other over used cliched terms. They are not part of management or operations.

Executives are not obliged to follow the red team's advice or recommendations; they are only obliged to listen carefully and consider if they are suitable for implementation. Post-implementation, executives will be obliged to review their operations in the light of the prior recommendations of the red teams so that better learning can happen and be captured for future operations. The red team does not do operations, it is not the boss. The executives are responsible for the operations and results. The red team provides feedback, reflections but has no power to implement, reward or punish. Red team never says 'I told you so' irrespective of whether things have gone right or wrong; they take no credit or flak for success or failure of operations - that belongs purely to the executives.

Red Teaming

Red Teaming are a large set of tools and techniques that take time to learn, taught to people with prior operational experience and high level of maturity. Red Teams are friends who are playing the role of the enemy. Red Teams will face resistance and hostility. Red Teams are people who will pick holes in your plans and shred your strategy during the day and yet party with you in the night. Their level of development is such that they will have to think and act like the enemy, be the enemy so that they can help their friends. Red Teams often do not have automatic rights on most things, they will have to engage and negotiate at every turn. They have to be nice to you to you before you will consider their help in tearing down your own plans - see the complexity in human interactions here? Red Team exists to falsify the organisations' and its executives' theory.

It is important to remember that Red Teams and Red Teaming is not 'process driven', it has been described as an art, something to help with intuitive decision making. To convert them into 'tick boxing' so that we can claim we have a Red Team who have done the Red Teaming is very tempting so that operations staff can move on with carrying out their high pressure functions on a day to day basis but would be an expensive same side goal.

Healthcare needs Red Teams

Essentially, one of the fundamentals of the army is the business of protecting lives and minimising loss of life; like healthcare I suppose. Evidence based healthcare has huge problems and still in its infancy. Even if enough good evidence was available the complexity of healthcare means that the decisions will still be very different from many other industries. While other industries will need Red Teaming to look at from the competition's perspective, healthcare especially the NHS, needs Red Teams to look at itself. That will be an even more specialised art. We need that art and those artists urgently.

Do we in healthcare have the guts or the maturity to have red teams?

© HEMADRI

Follow me on twitter @HemadriTweets

Further reading

UK version of Red Team https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/142533/20130301_red_teaming_ed2.pdf

US version of Red Team http://usacac.army.mil/cac2/UFMCS/Repository/RT_Handbook_v6.pdf

Bad Apple Theory in healthcare

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We know how bad apples can spoil the barrel, i.e. negative members can cause dysfunctional groups. I came across Will Felps work on it, will be very interesting to check out.

Felps et al say that there are 3 types of ‘bad apples’ (negative member of a group)

- withholders of effort

- being affectively negative,

- interpersonal deviants (violating important interpersonal norms)

They then go on to describe the groups responses to the negative member as

- motivational intervention (changing the negative person’s behaviour)

- rejection (removing the negative person)

- defensiveness (protecting one’s own self)

Felps says that ‘Each of these three responses have a common foundation; the desire to improve an aversive experience, but their intention varies’ as mentioned in parenthesis above. They  say that if motivational intervention or rejection were successful then a negative member never becomes a bad apple.

The work is mainly analytical rather than aiming for any resolution of the issues but they do touch on how the bad apple effects are moderated by determining perceived impact severity –

(1)    intensity of the negative behaviors exhibited

(2)    the group’s interdependence,

(3)    whether outcomes are successes or failures,

(4)    and the team mates’ coping abilities.

They also talk about the group’s ability/inability to cooperate and how low power groups looking to leadership to resolve the issues.

Here is the interesting radio link for an introduction to the work http://www.thisamericanlife.org/radio-archives/episode/370/ruining-it-for-the-rest-of-us

This is the link for the full academic paper http://books.google.co.uk/books?id=RKkxJnn73UoC&pg=PA175&lpg=PA175

My short commentary:

While the bad apple theory is very attractive I would reflect on whether the 'bad apple' behaviour and effect is topic dependent or person dependent. It is possible that a particular topic brings about a genuine principled disagreement from a team member who is so affected by the inability to influence the team hence shows 'negative' behaviours resulting in negative effects. History is equally full of examples where entire groups and even nations have been wrong and at that time any voice of wisdom would have been identified as a classic bad apple. A 'bad apple' in one topic might be the best bet team player on a different topic. However, the negative behaviour may not be topic dependent but entirely person dependent; this brings to fore a new set of issues on why such a person was employed or brought into the group; if the behaviour is recent/new an exploration of the team dynamics that brings forth such behaviour from individuals would be worthwhile.

I also caution that sometimes 'bad apples' can be early lone warriors too. These often tangential maverick thinkers and doers are also important for any societal or organisational progress.

Felps description of the 3 types of bad apples and the 3 ways in which groups respond to negative members are certainly seen in healthcare including amongst clinicians. The peculiarity with healthcare arises from the need to practice evidenced based medicine in the face of lack of good evidence by these precious resources called clinicians. This conundrum is compounded by rigidly hierarchical structures and high regulation in healthcare posing very unique and highly complex leadership challenges. Bad apple behaviours and effects as described by Felps are very naturally observed but allowing it in healthcare or dealing with it by either motivational intervention, rejection or defensiveness as we may be currently doing is likely to have as yet not understood exaggerated negative outcomes. Throw in the highly individualistic style of practice amongst doctors and mix becomes even more unstable. That cannot be good for healthcare.

Felps does not attempt to resolve it, quite rightly so, as this is more complicated than it seems.

There are times when system issues would be exhausted and a purely personal behavorial issue remains. The problem comes when bad apples do not recognise themselves despite well meaning evidence and advice. More worrying is when they recognise it within themselves but fail to acknowledge it - that will be breath taking arrogance usually leading to a big fall.

In democratic groups, due to its political nature the NHS could be called a democratic group, the success of the majority is judged by how well the minority is treated and a quote misattributed to Voltaire is 'I disapprove of what you say, but I will defend to the death your right to say it'. Perhaps these apply to the ‘bad apples’ as well. Real life is full of very mixed people, we could disengage (easy option) and lose valuable opportunities to develop ourselves. We could remain engaged and learn a mature way of thinking. Whichever we chose it will not be easy.

©M HEMADRI 

Follow me on twitter @HemadriTweets

  My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 

Duty of candour: Voluntary or statutory?

Duty of candour: Voluntary or statutory?

Candour is the quality of being honest and telling the truth, especially about a difficult or embarrassing subject[1]. When things go wrong and especially when patients are harmed whether it is due to natural circumstances or due to error by individuals or systems candour becomes very important. One of the components of such candour is to offer an apology to the patients and their families. It is important to understand that as clinicians we may not be apologise for in a ‘conventional’ sense when there is no individual error is involved; what we would be apologising for in all cases is for the fact that the patients’ expectations were unable to be fulfilled on that occasion.

Compensation Act 2006 states: ‘An apology, offer of treatment or other redress shall not of itself amount to an omission of negligence or breach of statutory duty. The medical indemnity providers have always held a similar view that apologising does not put a clinician at risk of being accused of anything in the future – it is not an admission of liability.

In the document ‘The Coalition: our programme for government’[2] it says "We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong".  The words ‘will’, ‘require’ and ‘always’ seems to indicate that the government is inclined towards introducing  statutory candour or some version of it.

The CMO has been recommending a statutory duty of candour for a good few years and there are currently deliberations including the GMC on this subject. There has been parliamentary health select committee recommendation to consider this subject.

Understandably patient groups especially the AvMA are in full support of a legal duty of candour; understandable because of the powerful case studies[3] they use where a statutory duty could have either avoided prolonged and vexatious interactions with authorities involved in those case studies or would have helped to bring events to a closure quickly. 

The MDU does not support the consideration of a statutory duty of candour based on the argument that there is already an ethical duty backed up by adequate GMC sanctions.[4] The MPS also seems to take a similar view. The NPSA’s new ‘being open’ policy (as opposed to its ‘open disclosure’ policy) is based on the premise that doctors apologising would prevent many unnecessary complaints and possibly some of the litigation that follows. There is international evidence that litigation occurs less often when an apology is offered and accepted upfront.

The GMC guidance on good medical practice[5] states ‘‘if a patient under your care has suffered harm or distress, you must act immediately to put matters right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened and the likely short-term and long-term effects’’. However, a 2008 survey by the MPS[6] showed that while more than 90% of professionals believed that patients are less likely to litigate after errors if they received an explanation and an apology but only 68% were willing to be open when something went wrong. Clearly the issue of liability and blame still plays in the minds of doctors.

This raises the question whether the duty of candour should be statutory or mandatory.

Clinicians especially doctors really would not want statutory duty of candour as they would like to think that they are doing the right thing because it is the right thing and not because it is simply required by law. The GMC and other bodies, regulatory or not, take a very poor view of lack of transparency. Actioning after an event of low transparency is like many other triggers may turn out to be subjective, discretionary and inconsistent. However, in practice once the issue reaches the 'authorities' there are significant consequences which inevitably follow. Therefore a culture change route is preferable for clinicians.

The next issue to consider is how we design a response to the call of ‘duty of candour’. What the profession needs to understand is whether there was a rising trend that doctors and other clinicians are getting less transparent, if there is no such trend whether there are frequent examples of lack of candour. There seems to be no general trend that doctors are getting less transparent. Hence, a culture change approach using the voluntary duty supported by a strong view from the GMC and other bodies would certainly make a difference from the perspective of clinical professionals; with aberrant doctors dealt with strongly by using the full force of current systems. 

There are however, very frequent examples of outliers. This is when we have to recognise that institutional candour is a different situation. While individuals are all for openness, the current system of risk, clinical governance, complaints and legal actions inevitably raises doubts on the relevance of the extent of candour and its impact on future action against organisations. Further, often in inefficient and overspent circumstances or in situations of poor organisational vision, what is not required by the force of law or the force of higher authority is actively prevented from happening. This is understandable from an organisation's perspective but would be unacceptable to patients. There are examples of individual clinical candour followed by organisational resistance that happen in sequence. This is obviously unsatisfactory.

On balance, it seems that under current moral mores of our society a statutory duty of candour is probably going to be inevitable.  The question is of course is whether individual clinicians or the organisation would be legally responsible for the statutory duty of candour. It would make sense for the organisation to be responsible for such a statutory duty. The issue of candour after serious untoward incidents has extremely personal and wide ramifications at the same time, that it becomes clearly outside the remit of individual personal clinical responsibility. Further, organisations and organisational responsibility is likely to cover everyone in the organisation which would include doctors - any aberrations on the grounds of candour by doctors would therefore be dealt with by their organisation and by the GMC.

There might be a case for parallel dual responsibility (which has the risk of diluting responsibility) or for purely individual responsibility (where it could become 'fault', 'witch-hunt'  and 'scape goating' usual suspects). In a broad sense since the responsibility for quality moved from consultants to chief executives in the mid 80s, candour as such should therefore be an organisational responsibility delivered by individuals rather than individual responsibility enforced by personally applicable law.


© HEMADRI

Follow me on twitter @HemadriTweets

The department of health has launched a consultation on duty of candour: http://www.dh.gov.uk/health/2011/10/candour-consultation/ Please respond to it.

 

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[1] Cambridge Advanced Learner’s Dictionary

[2] The Coalition: Our programme for government: http://www.direct.gov.uk/prod_consum_dg/groups/dg_digitalassets/@dg/@en/documents/digitalasset/dg_187876.pdf

[3] http://www.avma.org.uk/pages/legal_duty_of_candour_-_robbies_law.html 

[4] http://www.the-mdu.com/section_medical_students/topnav_News_3/hidden_Article.asp?articleID=2011&contentType=Media+release&articleTitle=MDU+supports+apologies+to+patients+but+says+no+need+for+duty+of+candour

[5] http://www.gmc-uk.org/guidance/good_medical_practice/relationships_with_patients_open_and_honest.asp

[6] http://www.medicalnewstoday.com/articles/127194.php