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- Introduction
- Recent Management and Clinical Leadership Trends
- Leadership Structures in Community and Mental Health Services
- What Should Service Management Deliver?
- A Concept of Clinical Management Partnerships
- Conclusions
- References
Introduction
This paper details the joint clinical and management leadership approach applied in Community and Mental Health Services, Auckland Healthcare. The approach reflects the concept of partnership between management and clinicians that applies across different levels of management in the Auckland Healthcare structure. By way of introduction, the paper also summarises the shifts in management and clinical leadership in Auckland Healthcare since the early 1990s that led to the focus on clinical management partnerships.
Recent Management and Clinical Leadership Trends
The predominant shift in management in Auckland Healthcare since the early 1990s has been the move to service management concepts, instead of geographical/hospital management.
The previous triumvirate management structure, which included a medical superintendent, head of administration and head of nursing, was replaced by a structure combining service management and general management.
The shift to service and general management developed from the recognition of the need to bring management skills and accountability concepts into health. The health reforms openly articulated the view that the public health sector was not as well managed as the private sector. The move to service and general management aimed to create a structure that would allow the introduction of private sector management principles and skills into this public sector health service.
Initially, the introduction of management leaders into public sector health served to disenfranchise clinical participation in development and leadership to some extent.
The ensuing phase of management-driven attempts at cost management served to quickly highlight the role of clinicians in driving costs in health systems. Increasingly, the significant role of the consultant and team in affecting average length of stay, choice of procedures, choice of diagnostic tests and other key cost drivers was recognised.
This prompted moves to engage clinicians in an understanding of how their behaviour affects financial and behavioural outcomes. Over time, this has evolved to a view that recognises clinical behaviour as a significant determinant of effectiveness and costs and involves clinicians in decision-making and accountability related to strategic direction, service development and resource management.
Leadership Structures in Community and Mental Health Services
The key principle behind the service management approach in Community and Mental Health Services has been to acknowledge the competencies of both management and clinical staff in leadership.
The focus is on fostering an appreciation of both sets of competencies and both sets of demands. In addition, the approach aims to achieve best and most efficient use of resources. As a result, structures do not follow an inflexible structure but differ between clinical units within Community and Mental Health Services.
Clinical consultants are an expensive resource relative to business managers. Thus, where Clinical Coordinators head a clinical unit, they tend to be supported by a business manager to relieve them of tasks that represent inefficient use of their time. This is the structure used in Sexual Health Services, where the Clinical Coordinator heads the Service and a business manager reports directly to this head.
It should be noted that clinical leadership is not limited to medical staff. For example, non-medical clinicians manage services in Mental Health, eg, Eating Disorders and Child, Segar House (Psychotherapy) and Maternal Mental Health .
In some clinical units in Mental Health Services, a co-management approach with joint responsibility has been established. For example in Child and Adolescent services and Health Services for Older People [See Cranstoun/Yuvarajan paper].
The focus on a clinical management partnership is very necessary to close the gap in mutual understanding of each party’s particular skills, knowledge and orientation.
This gap in mutual understanding was highlighted in a survey of 850 hospital staff which revealed a range of profession-based attitudes and beliefs. 1 Unless considered and addressed, these attitudes set the limits on efforts to promote more outcome-focused and financially-driven approaches to health care organisation and management.
The study revealed significant differences in the beliefs of medical, management and nursing staff as to the degree to which clinical decision-making should consider resources issues and, thus, the extent to which clinicians should be held responsible for the resource implications of their practices. Similarly, there were significant differences in the degree to which different groups believed that work process control structures and methods, for example, protocols and clinical pathways, should be applied to clinical work.
The study also showed that the greater the extent to which the organisation structure adopts a collegial “bottom-up†versus a “top-down†approach to management, the more consistently all groups will tend to take a financially realistic stance on the intersection of clinical and resource dimensions of care.
Awareness of these attitudinal differences has contributed to approaches to involve all staff, including medical and non-medical Clinical Coordinators, other clinicians and Service Managers, in decision-making. For example, non-medical clinicians in Mental Health Services are represented at decision-making level by professional advisors who represent the professional needs of each specialty represented in the service (psychologists, nurses, occupational therapists and social workers).
Such approaches aim to ensure that all parties contribute to decision-making and service development, and create the necessary buy-in to any change in service delivery.
In addition, service leaders in quality, human resources and finance are involved in the decision-making teams. This team approach has been successfully applied in strategic planning and business planning in Mental Health Services.
What Should Service Management Deliver?
The General Manager’s expectations of clinical unit management in Community and Mental Health Services include:
- A high level of objectivity across the clinical unit and the whole service.
- Decisions balance the requirements of both clinicians and managers.
- A multidisciplinary approach to decision-making and service delivery.
- Wide promulgation of financial and output information such that staff are aware of issues for the business.
- An objective approach to service design and development that focuses on the consumer and service delivery; an effective design may not serve a clinician’s or indeed a manager’s needs and this should not influence the choice of structure or operation. This represents a significant shift in thinking as, historically, systems and behaviour in medicine were not necessarily client-oriented, ie, designed to assist client access, client needs, etc.
A Concept of Clinical Management Partnerships
As outlined above, revised management structures in some clinical units in Community and Mental Health Services have resulted in a situation where the Service Manager and Clinical Coordinator are jointly accountable for the management of that service, for example, in Health Services for Older People, Mental Health Services.
A similar partnership operates at the overall Mental Health Services management level; decision-making for Mental Health Services takes place in partnership between the overall manager for Mental Health Services and the Clinical Director for the Service. [NB: As the overall Mental Health Services management role is now filled by the General Manager for Community and Mental Health Services, the Clinical Director reports to the General Manager in this partnership.]
The intention is to lead by example; the partnership between the Clinical Director and General Manager (acting as Mental Health Services manager) is a model for clinical/management leadership at different levels throughout the service.
Effective clinical management partnerships are based on clear delineation of responsibility. The manager does not have a role in clinical decision-making, even if that individual has a clinical background. Despite the level of clinical competence, the manager’s role is not to exercise that competence. The manager’s function is to support others to exercise their clinical competence.
Managers need to recognise the role that clinical decision-making plays in determining financial outcomes as well as outcomes with respect to effectiveness and outcomes in an organisational sense.
Similarly, clinicians need to recognise the very valid and complementary role of administrative managers in service operation, development and leadership.
Clarity around accountabilities is vital for effective functioning and performance review in a joint clinical management or co-management structure. A model for shared responsibility is used to explicitly outline accountabilities of each party within the clinical management partnership.
Joint managers work together to establish and agree the extent of accountability for different aspects of service management and leadership. This is then reflected in position descriptions and performance objectives.
Developing the joint accountabilities is essential as the concept of partnership is based on the principle of shared accountabilities. The extent of accountability for manager and clinician will vary, reflecting the strengths of individuals holding those positions. Thus, the assigned accountability for different tasks is not attached to the position but to the individual in that position and will need to be re-established whenever there is a change in personnel.
Conclusions
Clinical units within Community and Mental Health Services at Auckland Healthcare employ a variety of management structures. However, all are focussed on a clinical management partnership with recognition of the contribution of the skill set of each party.
The overall goal of partnerships in management is to ensure that “the whole is greater than the sum of its partsâ€, ie, that the best contribution from manager and clinician on service design and delivery is achieved. In addition, in successful joint management:
- all parties contribute relevant skills and abilities which are complementary to one another
- no party is disenfranchised
- the best and most efficient use is made of clinical and management resources.
References
- Degeling P, Kennedy J. Do professional sub-cultures set the limits of hospital reform? Centre for Hospital Management and Information Systems Research. University of New South Wales, Sydney, Australia. 1998.
