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.

MSc in Healthcare Improvement Leadership

Applications are now open for the second cohort of the MSc in Healthcare Improvement Leadership starting in October 2015.  This is a bespoke programme that has been developed jointly between University of Hull (Faculty of Health Sciences) Hull University Business School and Hull and East Yorkshire Hospitals and is open to all Healthcare Professionals.  

The first cohort (a mixture of clinical and non-clinical staff) have reported that the programme is “interesting, enjoyable and thought-provoking” as well as “blowing my mind with different perspectives of quality”

If you are interested in being a part of the second cohort and for further information please contact:-

Tracey Heath – Director of Enterprise

University of Hull

T.N.Heath@hull.ac.uk 01482464519

Further information:

MSc in Healthcare Improvement Leadership

A unique opportunity has arisen to undertake a Masters in Healthcare Improvement
Leadership at Hull University. This MSc programme is developed jointly between Hull
University, Hull Business School and Hull and East Yorkshire NHS Trust. This programme is
open to all healthcare professionals from primary, secondary and other health care sectors.

Aims

- To provide the participants with theoretical and practical understanding of the
concepts of quality improvement in healthcare delivery

- To equip the participants with practical tools to enable quality improvement

- To equip the participants with the attitude and ability to be a leader of healthcare
quality improvement

Objectives

- To explore the links between evidence, experts, experience, policy and practice.

- To understand the relationship between quality and cost

- To understand the concepts of shared baselines, local clinical protocols and the
improvement method

- To understand the modelling of the process of quality improvement

- To review tools available for healthcare delivery improvement

- To understand the relevance of measurement in improvement and to learn about
the tools to do so

- To understand the various kinds of leadership that brings about the preferred
response from colleagues using a selection of human factors and communication
methods thus defining the human face of quality improvement leadership

- To appreciate the importance of learning from immediate peers and colleagues.

Attendance Requirement
There will be 10 contact classes in the first year which participants are required to attend.
Other aspects of the course will be delivered by a combination of e-learning and support as
needed.

Modular progression
At the successful completion of first year there will be the option to take the qualification of
Certificate in Healthcare Improvement Leadership and to progress to a Diploma and Masters

©M HEMADRI

Follow me on Twitter @HemadriTweets

 

Declaration of interest: I teach some parts of the course. No current financial interest.

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

Skin in the Game

DO DOCTORS AND NHS MANAGERS HAVE ENOUGH SKIN IN THE GAME?

Skin in the game is a term mainly used in the financial world where it is thought that those persons who are playing the game (e.g. fund managers) should have their own money and reputation involved so that they are as rewarded or as damaged as the people on whose behalf they play the game (i.e. their customers, investors). Philosopher and author Taleb has ignited a debate on the importance of this, he points to a Hammurabic code where if a house were to collapse and kill the owner of the house then the builder will be given the death penalty - now that is some real skin. This blog has already written on how Warren Buffet would not take a fee unless he crossed a certain level of achievement for his investors (http://successinhealthcare.blogspot.co.uk/2012/01/getting-paid-for-performance-buffet.html); apparently Buffet also has his own money invested along with his investors - he has enough skin in the game.

This got me thinking on what kind of 'skin in the game' we have in the NHS. Of course that is a large one to put out in a short blog. Lets try a limited short version.

In the past when doctors were employed as consultants in the NHS there was a requirement to live within a defined distance of their hospital so that they can respond to urgent and emergency calls when they are on duty and also help their colleagues when necessary even if they were not on duty. In the past consultants had an obligation to let the hospital know if they will be out of the area (even if they were not on call or on annual leave). Doctors were paid some money as relocation expenses to facilitate the same.

This obviously meant that the doctors working in a hospital lived within the catchment area of the hospital. In the event of an urgent need for healthcare for the doctor or for their families, they are highly likely to attend the hospital where they work. The success and failure of the hospital had the potential to directly affect them. In the last decade or so, the obligation to live within the local area seems to have disappeared due to a combination of societal changes of both spouses working and the officialdom seeming to demand that the doctor be available only when rostered to do so. However a large number of permanent senior doctors still live in the catchment area of their local hospitals. By definition there is skin in the game - if your hospital mortality or morbidity or general services were bad you and your family were likely to be affected by it.

The other aspect for consultants in the NHS is many consultants expected to work for many decades in one hospital, they do not expect to move. This has seen a slight change recently but it is substantially true that you would generally not find NHS substantive consultant post holders move very often. They develop, grow skin into the game. There is of course the issue of excess skin in the game where people with too much stake take too much risk, perhaps in the case of NHS consultants it may be a case where due to their superior knowledge of local and national situation they learn to avoid personal risk while all the risks remain for their patients. The doctors have a reputation risk - this is really serious - so serious that a doctor can be struck of for damaging the risk of their profession; at a personal level the reputation is equally serious;  due to peer pressure and long service reputational damage can be devastating.

I am unable to find a historic or current requirement that states that executive directors of NHS hospitals were/are obliged to live in the catchment area of their hospitals. I know of many hospital directors who do not live in the geography covered by their local hospital. This means in reality they have not much skin the game. In contrast to NHS consultants, board directors stay in post only for a fraction of the time that a consultant stays in post - compared to consultant appointments, executive director appointments are practically musical chairs or passing the parcel. Again there is not much skin the game. Of course there is a reputational issue but with performance measurement in the NHS for managers not being so accurate as say for a financial fund manager a large gooey fudge substitutes for reputation.

I don't know how practically applicable the above thoughts are. I have already written about the fact that NHS board director contracts have no reward or punishment for anything other than financial performance (Whose job is it to reduce mortality? http://successinhealthcare.blogspot.co.uk/2013/06/whose-job-is-it-in-nhs-to-reduce-deaths.html) Modern life and employment conditions may mean that we may not be able to demand that people live where they work. However we do need to find a way to ensure the skin in the game for NHS managers and directors; increase skin in the game for doctors.

Perhaps a starting point might be to publicly declare if they live within the area of the hospital where they work and how long have they lived within the area (not asking for private addresses, just for HR to declare if they live within the area). Perhaps remuneration and penalties should be linked to quality of performance (when we get around to understanding how we can measure quality meaningfully). We must think of other ways that suit the modern world to increase skin in the game. Healthcare is person to person business, very important for healthcare professionals to remember - no skin means poor game.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Whose job is it in the NHS to reduce deaths and complications?

Recently there is an increasing concern about mortality and morbidity in the NHS. Let us for simplicity say that people are asking whether the death rates and complication rates can be reduced. People are asking if there are any avoidable components in relation to deaths and complications and whether those avoidable problems can be eliminated or at least reduced to minimum. People are also want to know who is responsible or accountable for ensuring lower death and complication rates.

NHS Directors

NHS trusts are in the business of delivering healthcare to their populations – that is the essential purpose of their existence. So it may be reasonable to assume that the directors, who are the top bosses of these trusts  and their bosses (SHA equivalent, NHS England directors) will be assessed and rewarded against clinical quality parameters of which deaths and complications are core.

Apparently not. The contract for the managers especially when it comes to pay uplifts and bonuses are very specific. I quote:

''It is an essential criterion of the performance bonus scheme that the organisation achieves its financial control target as agreed with its grand parent organisation (see paragraphs 64 and 65 below).

Where an organisation fails to do this, all its very senior managers will be treated as Category D performers and so no awards (either annual uplift or performance bonus payment) will be paid to them

The annual uplift will be applied to the basic pay being paid to the post holder (which would include any long-term RRP payment), provided that:

the organisation achieves its financial control target; and

the individual concerned is judged as performing at Category A, B or C.

Those in Categories A, B and C will receive this annual uplift to their basic pay, which will be pensionable

Those in Categories A and B will receive, in addition to the annual uplift, a non-consolidated bonus payment, provided the essential criterion is met –

i.e. that the organisation achieves its financial control target. Bonus payments will be non-pensionable, non-consolidated one-off payments

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/126865/pay-framework-vsm-strategic-and-special-has-pcts-amb-trusts-updated-july-2012.pdf.pdf ''

So it is seems the only officially contracted criteria to be eligible for a pay uplift and bonus is meeting the financial target (and something woolly about being classed as A, B or C. In any case if you don't meet the financial target it is an automatic D which means no pay uplift or bonus irrespective of how much quality is improved and mortality/morbidity is low

What do you think might be happening in a manager's mind when priority setting? Which director will be prepared to have a very low mortality and morbidity and yet be classed as a failure and given a D. If ever a CEO was prepared to do that what do you think that their directors's mind would think given the fact that various director's pay are set as a percentage of their CEO's pay. What does it tell Jo public when the Finance Director's pay is linked to and set at 75% of the CEO pay and all other directors get a lesser percentage? One lovely chain where there is clear financial incentive to reach financial targets and ensure the CEO gets a higher pay. I am sure my understanding is not perfect but it looks like a conflict of interest built into a contract - you could not make it up if you were writing fiction. Where do you think the emphasis will lie? No guess work – it is explicit – financial control target it is and nothing else.

Now do I think for a minute that any CEO or director gets to work and says 'kill patients but save money', heck no. But we have all heard about subliminals, motivation, contractual obligations playing a part in how we perform. It does not sound sweet.

REGULATORS

We then have regulators to oversee that trust bosses who are contractually only obliged to serve the financial agenda are still meeting some sort of standards that matter to a publicly funded healthcare system – i.e. clinical quality with death and complications at its core.

Lets look at some of the regulators purposes:

Monitor: Our main duty is to protect and promote the interests of patients. We do this by promoting the provision of health care services which is effective, efficient and economic, and maintains or improves the quality of services.

CQC: We make sure hospitals, care homes, dental and GP surgeries, and all other care services in England provide people with safe, effective, compassionate and high-quality care, and we encourage them to make improvements.

GMC: Our purpose is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.

But let us look at how it actually works out

CQC

The CQC talks about safety and quality but when you look into what they actually say there is no specific mention that organisations will be assessed against their death and/or complication rates

http://www.cqc.org.uk/public/what-are-standards/national-standards

For God's sake how else do you assess care quality if you do not start with death and complications.

MONITOR

It is the government's aim to provide independence to NHS trusts by allowing them foundation trust status. Clinical quality especially reducing mortality and morbidity is not a criteria for affording independence (though there is assessment on whether the trust is governed properly)

http://www.monitor-nhsft.gov.uk/sites/default/files/publications/An%20introduction%20to%20Monitor%27s%20role%201%20April%202013_0.pdf

With 10 out the 14 trusts under Keogh review being Foundation trusts, it is reasonable to wonder what actually the question 'well governed' means for Monitor.

BOSS' BOSS – The Grandparent Organisation is DoH

It looks like the department of health may have the overall responsibility for mortality and morbidity reduction though those are not explicitly spelt out in their website

https://www.gov.uk/government/organisations/department-of-health/about

It has taken nearly a decade and half after HSMR was introduced that DoH is making some moves to look into this. Perhaps better late than never. But as the grandparent organisation DoH is responsible for setting the contractual framework like it is in the first place.

What about doctors and nurses?

Doctors 

Doctors bonuses in the form of CEAs are based on quality of service and hopefully given to excellence. There is no requirement to demonstrate reduction of mortality or morbidity but the hope is that those two essential measures of quality will be considered explicitly when these awards are made. That is sometimes the case, sometimes that is not the case. In theory it is possible for even the highest award holders to hold the awards without ever demonstrating a decrease in mortality or morbidity.

https://www.gov.uk/government/publications/clinical-excellence-awards-2012-application-forms-and-guidance

Then of course there is the GMC who will come down on doctors who are caught out mainly due to significant single incidents which are reported. More recently the GMC due to its revalidation format demands 'quality improvement' though does not explicitly demand reduction of deaths and complications. 

Nurses

Agenda for change does not speak explicitly about improving clinical quality or reducing mortality/morbidity.

http://www.nhsemployers.org/PayAndContracts/AgendaForChange/Pages/Afc-Homepage.aspx

So who is responsible for deaths and complications in the NHS?

It is everyone's job but no one is required to do it and nobody is responsible or accountable for it.

It does not say in anyone's job description or contractual terms that 'it is your contractual duty to seek and achieve a reduction in mortality and morbidity of your patients and when it is not achieved to provide a reasonable explanation of why they have not been achieved and what you will do to achieve them'. Nobody's pay scale is linked to a reduction of mortality and morbidity. Therefore no one is responsible or accountable for deaths and complications. People do it as an optional extra, as a gesture of goodwill, from the goodness of their hearts, as a side effect of their day jobs. There are so many organisations all claiming to be working for patients' protection, quality and so on but all they do is announce diktats on what others should do; they do not hold themselves accountable on behalf of or as representatives of their members by measured reductions in avoidable deaths or complications. It is always everybody's job, somebody else's job, each one of us wants to hold somebody else to account but never us.

That is why it is so very impossible to deal with and so very difficult to get meaningful sustainable improvements. The contractual requirements, recognition and reward structures are all wrong in the sense they are not geared to look for quality improvement. Looks like this is a case where the structure and process results in just the expected poor outcome.

There are solutions – it is to use healthcare management methods to manage healthcare and not to use as we do now - business, financial, manufacturing, service industry or other management methods for healthcare. Whether there is enough interest, knowledge or expertise to do so is highly questionable.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Further Info: I am informed by an NHS FT Board Director that the NHS Board director's contract that is referred to in this blog does not apply to NHS FT Chief Exec or Board Directors.
It will be interesting to find out who it applies to.
Hemadri
15 August 2013

Clinical Leadership 'Development' - have we got it right?

Development has two components; in order, first is technical skills (hard) and second is personal (so called soft).

Technical skills in my view has two steps core professional skills (how to do the best) and core generic skills (how to do the best for everyone, every time, everyday). Many of us are good at our core professional technical skills (eg surgery, finance, radiology, facilities, HR, cardiology, etc) but it is very well known that in healthcare many of us are unaware of core generic technical skills (evidence, shared baselines, operational data analysis and data tracking, data based decision making).

The NHS is and has been focused for a while on 'leadership', 'social movements', 'change' and such similar things.

My problem with this is profound. I believe that core generic technical development should precede personal development. Personal development methodology is very profound and is designed to promote self-awareness and self-belief. The risk is when the personal development comes before the technical development, people become so convinced about themselves and what they are doing that they feel that technical development is a non-essential trivial distraction.

What is also interesting is the technical skills are easier to teach/learn, assess and practice though most people would think it is difficult and personal development is far more difficult to achieve and demonstrate though most people would think that they have 'got it' after a few sessions.

I have huge concerns that at a local level the deaneries and SHAs do not do this and at a national level personal development happens at a fantastic level to NHS persons who mostly do not have the technical development. 

The fundamental message here is, one must know what/how to do it before they begin to believe they can do it.

Clinical Leadership

One of the weirdest ideas of leadership and leaders is about being a 'senior', board member, top management, etc. Please let me explain. Leaders by default definition have followers; no followers - no leaders. Leaders become and remain leaders because followers allow them to do so. This does two things - the leaders begin to believe that they belong where they are (in leadership positions) due their 'own' and followers become passive because they put the leaders in there in the first place and do not want to admit wrong judgement. Further factors are mathematical politics, allowing time and running on reputation. There are glaring examples in politics that many of us would be aware of.

Once this happens, leaders begin to believe a bit too much in their own credentials. They forget that the fundamental source of all leaders and leadership is followers. The leaders who are by this time out of touch, deluded and completely in their own world begin to substitute the power of followers by the power of rules, law, agenda, reward, punishment and so on. Interestingly and correctly these are the tools of managers/administrators. The tension starts building, leaders become ineffective, leaders and followers become frustrated, external pressures build on what is perceived as 'failing' leaders, leaders use even more top down management methods because this is seen as going 'forwards' rather than stopping and getting back in touch with what put them there.

So the perpetual confusion between the roles of leaders and senior managers results in the unwillingness to recognise that all managers are NOT leaders and not all leaders will have good managerial skills (try telling that to any of your board members, medical directors, clinical directors or similar, that they are a 'director' or 'senior management' but not a leader). Some are blessed with both, both need some of the other's skills; what is crucial to understand is that leadership and management are fundamentally different. The sources of power of the managers are authority, position and mandates; the drivers are policy, guidelines, targets and the deliverables are the successful completion of what they are required to do. For managers failure is something to avoid.

The sources of power of leaders are first and foremost their followers; the background is usually due to knowledge, expertise, passion, and deliverable for leaders is their ability to bring people together for a cause if possible with success. Failure of a task is a learning experience for leaders and a true leader will rejoice the coming together of their followers irrespective of the eventual outcome.

In this context I would suggest that doctors are in a unique position. Doctors would and should quite simply be able to differentiate between managerial role and leadership role. Doctors due to their power of knowledge and skills in their chosen field need to aim to deliver the best care in the pursuit of clinical excellence that will actually be their 'management' role. Doctors as managers as currently taught in deanery 'management' courses completely miss this point. Doctors need to manage their time and resources to provide clinically superior care, that is the success of a doctors real management role; the management of their own clinical care delivery. That is the role of every doctor including the clinical director and the medical director. I could argue that for doctors good clinical management is the only management that is relevant.

We have to understand that most of us will not be leaders and we have to develop good followership traits along with management skills. Even those who are leaders must support other leaders whole-heartedly. Some doctors would demonstrate leadership. In my view the leadership is not really linked to any title or position in their place or work. These leaders should be recognised and supported. This would usually but not all the time be based on good clinical management but not necessarily related to it.

One of the first things to do therefore is to de-link managerial hierarchy from leadership situations. That does not mean that some managers would be good leaders or some leaders would be good managers; it simply means that there is no formal link or requirement for managers to be leaders or vice versa. The next step is to recognise that leaders could be anywhere in the hierarchy and create an obligation on managers to recognise and enable these persons to be effective.

These would result in Successful Healthcare.