Editorial - Vol 4, No 8:  Leadership and the Management of Change in Clinical Settings

In this month’s edition of Healthcare Review – Online^TM, Online, we present the proceedings from the "Leadership and the management of change in clinical settings" forum held in Auckland, New Zealand, on 2 August 2000.

The one-day forum was jointly presented by The University of Auckland’s Business School and its Faculty of Medical and Health Sciences, and was convened by R H Penny Ltd.

The "Leadership and the management of change in clinical settings" forum opened with a welcome from the Chair, Mary-Anne Boyd, Manager Integration/Provider Relationships, Waitemata Health.

Boyd noted that changes in health management are taking place internationally. She emphasised that multiple styles exist in the management of change and highlighted the fact that the effective options will be different for different settings. However, in all cases, good relationships between clinical leaders and managers are fundamental to good health management change. She noted that, because of the range of different experience and effective approaches in managing change, there was much to be gained from bringing together speakers from a variety of settings to contribute to the current forum.

Mr Hugh Ross, Chief Executive, United Bristol Healthcare, UK, presented a brief case history of the Bristol Royal Infirmary (BRI) experience relating to past performance in paediatric cardiac surgery.

United Bristol Healthcare comprises hospital and community services and operates a budget of approximately £200m per annum. It is one of the largest hospital and community service National Health Service (NHS) Trusts and is the major NHS teaching and research centre for the south west of England. The Trust includes nine hospitals and 19 community bases. It employs 7,500 staff and serves a catchment population of 250,000 for local services, 1,000,000 for hospital services and over 3,000,000 for specialist tertiary services.

BRI is the largest hospital in the Trust and was one of the first hospitals to adopt a clinical leadership model in the 1980s. Its management structure includes 13 clinical directors (refer slide 2) responsible for operating directives.

Paediatric cardiac services started at the BRI in the 1970s with one surgeon. Services were officially recognised in 1984 with targeted funding provided for children aged less than one year. The balance of paediatric cardiac services continued to be treated as an offshoot of adult cardiac services.

The first publicly expressed concerns about the high rates of mortality and morbidity associated with paediatric cardiac services at BRI emerged in August 1990, although there had been concerns voiced at earlier dates.

The consequent General Medical Council investigation directly resulted in the CEO of BRI and the senior of the two surgeons involved being struck off (the second surgeon was dismissed from the Trust).

A public Inquiry followed, starting in April 1999 and covering the period 1984-1995, although families had been involved from the early 1970s. The Inquiry’s report is due in November 2000. It is expected that the report will be used to reflect the overall state of the NHS over that period.

A "tidal wave" of litigation has accompanied these events.

However, alongside these was a lack of teamwork within BRI, which Ross cited as a key cause. In Ross’s view the issues outlined above would not have mattered if the clinical teams had worked well. There was little collaborative discussion, co-ownership or shared audit, and it was this situation that proved to be real impediment to the recognition of a series of warning signs.

In addition, there were issues related to the ability to effectively interpret data that were only eventually resolved by bringing in external experts.

The 1991 UK patient charter had emerged as the first national statement of standards of service, but this had mainly addressed speed of treatment and length of waiting times with some reference to patient privacy and dignity. The Charter was not enforced effectively and management could operate as if the Charter did not exist.

Ross went on to cite other issues that emerged and to review the Trust’s response to them. These included issues related to adult cardiac surgery and to the practice of major teaching hospitals retaining organs for educational purposes. There were issues related to the very high-level media involvement. NHS organisations have been required to have a policy related to "whistle blowing" since 1993 but the key to success in this area has been in applying this to create an environment where staff members are able to speak out without fear or concern. Ross also cited the conflict between the Bristol Children’s Heart Action Group (BCHAG) and the Bristol Surgeons’ Support Group (BSSG). These groups are now involved in assisting in a lot of areas particularly related to building services that work for consumers.

As a result of the "Bristol case", there has been a need to internally rebuild services at BRI.

Improved methods of joint audit have also been important. Medical audit was formally discussed for the first time in the 1980s and funds were made available for this purpose. But the strong message was that audit was to be lead and completed by doctors and managers were not welcome, and there was no reference to multidisciplinary teams.

Publicity has been an important ingredient in rebuilding public confidence. For example, mortality rates are posted on the Internet. Publicity has been used to emphasise a new team and new service, increased work with patients and openness about data.

In his second presentation "Changing the Bristol Royal Infirmary culture", Ross detailed the structural arrangement for corporate governance at BRI (refer slide 7).

While the CEO of BRI has statutory responsibility for its clinical governance, day-to-day responsibility rests with the Clinical Director and the Director of Nursing, who co-chair the Clinical Governance Committee.

A range of initiatives in recent years has contributed to changes in management and governance. These have included, for example, the formation of two vital bodies to focus on clinical management: the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement.

NICE has two main tasks. The first is to evaluate new medical techniques (drugs, procedures, etc) on a rigorous and evidential basis. The second is to produce definitive treatment guidelines. This approach to developing guidelines has contributed to overcoming the "not invented here" syndrome.

The Commission for Health Improvement also has a two-fold role. The Commission is responsible for four-yearly inspections of every major health facility in the UK, involving rigorous assessment of processes and clinical practice. In addition, it undertakes special investigations of health care organisations with problems at the instigation of the UK Secretary of State. Unfortunately, this latter role has been more prominent than the former and the Commission is increasingly being seen as a "policeman" for the NHS rather than a developmental body that encourages the spread of good practice.

Ross went on to review activities in the last two years at BRI.

The aim at BRI was to become the regional and then the national leader in clinical governance, working within the government framework (refer slide 9).

In summarising what lies ahead for BRI, Ross noted the BRI Inquiry report, due in November 2000. It will be important then to remember the good work that has been done to date since the period of the Inquiry. He also noted the importance of a medical institution being an "organisation with a memory", that learns from incidents and moves on without repeating the same mistakes.

Ross also emphasised the impact on NHS developments of the ongoing conflict between the General Medical Council (GMC) and the British Medical Association (BMA), effectively the doctors’ "trade union" and the doctors’ regulatory body, which leaves the profession divided amongst itself.

A revalidation/accreditation system is likely in the future; it is not yet clear whether it will be the responsibility of the GMC or another organisation.

These and other issues, such as the demanding 1999/2000 winter, have led to considerable "soul-searching" about the NHS. The government’s response has been to evaluate the basis on which the NHS was set up and whether the system delivers an equitable and effective health care system. The conclusion has been that the principles on which the NHS is founded are still sound but that practices need radical reform and a huge injection of funds. The Government has committed NHS funding of £45 billion increasing to £60 billion over four years.

In summary, the government is taking on a significant level of responsibility and adding an unprecedented level of funding to make this work.

The NHS is embarking on fundamental changes and has come a long way in its clinical governance. Clinical leadership in a mainstream fashion is well in place and is now developing in new directions, for which there is clear Government support.

[View Mr Ross’s presentation, The Bristol Royal Infirmary (BRI) experience]

Mr Bryan Parry is Professor & Head of the Division of Surgery in the Faculty of Medical & Health Science of the University of Auckland, and one of three colorectal surgeons at Auckland Hospital. Until recently, he was Chief of Surgical Services at Auckland Hospital. He is currently President of the Surgical Research Society of Australasia, Executive Member of the Boards of Research and Colon & Rectal Surgery of the Royal Australasian College of Surgeons, and Chairman of the National Waiting Time Booking Systems Initiative for General Surgery of the HFA. He approached the topic of leadership in clinical settings from the viewpoint of a clinician leading a therapeutic team comprising other health care workers.

Parry has worked in four health systems internationally including the UK and Singapore in addition to New Zealand. Parry’s most recent experience with clinical leadership has been in his role as Chief of Surgical Services, Auckland Hospital. He took on the role without up-front resources, either human or financial, but built on the considerable goodwill that existed including a good relationship with his management "twin", the Manager of Surgical Services.

In particular, Parry emphasised the importance of goodwill between management and doctors to his success in the role.

Parry painted a picture of the "past era" of public hospitals: hospitals operating as a complacent bureaucracy with benign paternalistic medical leadership; boards made up of parochial lay politicians; an aggressive doctor lobby and acquiescent and mute patients.

He considered the changes in the heath care sector over recent years including the shift of the Ministry of Health to a "lean and mean funding body" and the rise of corporatised purchasing through the Health Funding Authority. A "factory management" approach to health care, disenfranchised doctors and worried patients have been products of this period of change.

Another important outcome has been the rise of the querulous litigious patient who has lost confidence that the public hospital will actually offer the services that the public has been lead to expect should be offered. Dealing with these more confrontational patients demands more time and effort on the part of the clinician.

More recent shifts in the health care system have increased the focus on clinical leadership.

Parry contrasted the Auckland Healthcare model of clinical governance with that of the Mayo clinic in Rochester, Minnesota, a principal entity of the Mayo Foundation. The Auckland model, which includes service management and clinical business units, operates a parallel management and clinical leadership structure at all levels of the organisation. However, delegated authority rests firmly with non-medical managers who, effectively, have support from doctors in an advisory capacity (refer slide 12 -13).

In the Mayo model, doctors hold the line management roles with delegated authority. Non-medical managers are accountable to doctors in an advisory or operational way. This model matches the structure in a university, where academics are in line management roles with administrative staff included in an advisory capacity (refer slide 12).

Culture clashes can occur between managers and doctors, often on the basis of personality differences. Other issues like differing expectations and wrong accountability, eg, a manager deciding on capex items, can contribute to difficulties in manager-doctor relationships. Parry illustrated this point by highlighting the marked contrast between doctors’ views of themselves and the management view of doctors, juxtaposing descriptors like ’self-sacrificing’ and ’patient advocate’ with ’manipulative’ and ’self-centred’.

Overall, most clinical leaders would take their role up again if given the same opportunity. Parry believes that this reflects a strong cadre in Auckland Healthcare of well-motivated, committed and skilled people who want to make clinical leadership work.

Parry referred to an ongoing revolution in the management of hospitals. Hospitals are increasingly filling a role as "places of last resort for the failures of social policy", such as the dying, the aged and the psychopathic, and hospitals were not designed for this purpose.

Parry sees co-location of private health care with public hospitals as a worthwhile possibility. This would provide increased opportunity for sharing the talent of doctors across the private and public sectors and could provide considerable support for an overloaded public system, particularly when "pressure situations" are created by, eg, high winter admission levels.

The past five years have seen a lot of doctors making clear and studied decisions to become involved in management roles. Clinical leadership will help to prevent the bureaucratisation of health care and to increase its focus on patient needs. Parry does not consider that a central bureaucratic organisation best meets the needs of patients. Effective clinical leaders will need training in health management and this must be integral to their medical training, not an "add-on" module. Organisations like CLANZ (Clinical Leaders’ Association of New Zealand) and The University of Auckland are providing good support in this area.

[View Mr. Parry’s presentation, Towards clinical leadership]

Dr Richard Frith, Clinical Director of Neurology and Clinical Neurophysiology, Auckland Healthcare, is the recently appointed Clinical Leader of Medical Services for Auckland Hospital. He is also Chairman of the Auckland Healthcare Charitable Trust.

In his presentation, "Issues and challenges for clinical leaders", Dr Frith considered clinical leadership from his perspective of a practising clinician who has recently accepted a role as a clinical leader at Auckland Healthcare.

In Frith’s view, clinical leaders must be practising clinicians. A doctor functioning in a CEO role should no longer be regarded as a clinical leader. Frith recognises a role for all clinicians, medical and non-medical, in clinical leadership but notes that, in the current environment, outcomes and quality are best driven by doctors. He considers that doctors are in the best position to obtain the co-operation of their colleagues.

The Auckland Healthcare experience has been that the best way to run clinical services is using a clinical leadership-manager partnership. Except in very rare cases, clinical leaders cannot do everything. Doctors need to recognise that others have skills they may never have.

Frith considered challenges to clinical leaders and the clinical leadership model in three categories: individual, clinical colleagues and organisation.

Individual

Frith reviewed the perception of doctors and some of the reasons why many people may not understand doctors’ behaviour. He cited defining moments in medical training and practice, including the need to deal with issues related to death and serious illness, and spoke of the nature of some doctors’ protective mechanisms to maintain emotional robustness. Medicine can create independent, self-reliant, high achievers who are often not aligned to group decision-making and may have difficulty with a global perspective. There can be real difficulties making this type of person into a clinical leader.

Issues that may arise for the clinical leader include:

Clinical Colleagues

Doctors who are clinical leaders can create issues for their colleagues. Some colleagues will have the expectation that a clinical leader will effectively be a "union representative" for clinicians. A refusal to "carry the flag" for clinicians may be seen as a betrayal or as the clinical leader "crossing the line" to management. Clinical colleagues without a broader view of clinical leadership may have difficulty understanding decisions that have been made.

Organisation

Questions relating to the clinical leadership model that may arise for the organisation include:
•	Are recent shifts in the health care system a return to the old nurse-doctor-manager triumvirate?
•	Who should be appointed as clinical leaders? This question relates to whether clinical leaders can be taken from non-medical professions;
•	Is there a career track for clinical leaders?

Frith noted that clinical leaders need to have clear responsibilities and accountabilities and that expectations of them need to be sensible. He warned of the pitfall of token appointments; appointees must be able to perform adequately, need to avoid a narrow focus and must not act as "union reps". Appointees must also be able to cope with strong clinician-management relationships.

In Frith’s view, clinical leadership can certainly work at a business unit level. He questions its success at a higher level because of the difficulties associated with one person filling two differing professional roles at such a high level. Frith believes the best option for leadership is to have clinical leaders and appropriate managers in partnership, each with their own clearly outlined responsibilities and accountabilities.

Good relationships between clinical leaders and managers override the need for a particular structure, to some extent.

[View Dr Frith’s presentation, Issues and challenges for clinical leaders]

Dr Jenny Carryer is Professor of Nursing, School of Health Sciences, Massey University/MidCentral Health and Executive Director of the College of Nurses, Aotearoa-New Zealand. By virtue of her different roles, Carryer has developed a close and reflexive relationship between nursing scholarship, the concerns of nursing practice and the political and professional context of health care delivery.

A major consequence of the events which have transpired in New Zealand since the passing of the State Sector Act 1988 has been the systematic destruction of nursing leadership in Crown Health Enterprises (CHEs) and then in Hospital and Health Services (HHSs).

As this destruction has taken place, there has been no simultaneous building of nursing leadership structures within community health structures.

Within the new health structures, a focus on efficiency, speed, precise measurement and technical improvements as ends in themselves have set managers and clinicians on a collision course.

Carryer referred to the high level of ignorance of people who have assumed nursing leadership to be irrelevant, both to nursing as a profession and for the successful running of organisations.

In fact, patient safety, comfort and mortality are demonstrably directly affected by the quality of nursing services. Carryer used as an example the Magnet hospitals in the US.

A hospital can be certified as a "Magnet Hospital" by the American Nurses Credentialing Center (ANCC) if it can show excellence in nursing service. The magnet award is the highest level of recognition awarded by the ANCC.

Magnet hospitals are required to meet certain criteria including the following:
  • A nurse executive on the highest decision-making body in organisation;
  • A high level of nursing autonomy reorganising care, and deploying resources;
  • Nursing services that exist in a flat structure;
  • An administration that supports nurses’ clinical decisions;
  • Good communication between nurses and doctors;
  • Nurses are salaried rather than paid wages according to hourly rates.

A 1999 study found that Magnet Hospitals had^{[ 1 ]}:
  • A 4.5% lower mortality rate;
  • Shorter lengths of stay;
  • Increased patient comfort and satisfaction;
  • Safer working environments;
  • Good retention of nursing staff.

Carryer noted pressures on nursing leadership from two directions: from nurses themselves and from others. Periods of excessive managerialism in recent years have trimmed the amount spent on nursing, leading to shortages and loss of experience in the nursing workforce. This has created an increased sense of vulnerability.

Carryer emphasised that the goals and perspectives of nurses and managers are generally very different: nurses tend to value caring, and focus on patients’ experience and holistic care whereas managers tend to value bottom lines, outcomes and profitability. The experience of nurse leaders is that they have had to embody this fundamental dichotomy.

The emergent public health model that is competing with the traditional medical model for the delivery of health care demands that the allocation of health dollars is made in light of the greater good of the population, not just the needs of individual patients.

Clinical governance is offered by some as a solution to current issues but usually refers to medical rather than clinical leadership. Clinical leadership potential among nurses remains largely untapped. Failure to include nurses in clinical governance arrangements will perpetuate the wastage of nurses.

Giving great responsibility without commensurate authority disenfranchises nurses, lowers morale and undermines their willingness to account for their professional performance and outcomes.

Despite ongoing issues, the last 20 years has seen significant moves forward for nursing. Nursing has moved from "occupational" to "professional" status. Nursing education has shifted from an apprentice system to the tertiary education sector, successfully infiltrating the university setting. Nursing’s conceptual or theoretical base has been moved from a system of trial and error to one that is increasingly based on research. In addition, nursing has pioneered a cultural safety focus in New Zealand’s health care system.

Nursing has forged new research boundaries, undertaking research in partnership with people and communities and giving importance to patient and community experience and to empowering individuals to take more control of their own health care.

The future will not be different unless we:
  • Embrace nursing leaders as a partner in decision-making at all levels of the health care system;
  • Respect nursing’s right to lead, determine and direct its own services.

[View Dr Carryer’s presentation, ’Leading but silently’ ]

Barbara Simpson, Senior Lecturer in Innovation and Change Management, Business School, The University of Auckland, presented "Leading when control does not work".

Simpson’s interests include issues of management and leadership in knowledge work settings. She draws on her experience as a research scientist and environmental consultant, as well as her ongoing management consultancy work with professionals such as lawyers, doctors, engineers and technologists, to illustrate the challenges that confront both managers and professional knowledge workers in contemporary organisations.

Simpson defined the knowledge-based organisation as an organisation that not only uses knowledge to achieve ends but also creates new knowledge, which in turn means that the organisation must be able to learn. She considered the hospital as an "organisation that learns" and noted that learning has been crucial given the changing environment in which New Zealand hospitals have operated over the last few years.

Simpson presented two models of knowledge production - contemporary and traditional - and then considered what "leadership" might mean in each of these contexts.

Traditional knowledge production occurs within disciplinary structures, deepening knowledge and increasing focus. Knowledge produced in this way is shaped by the norms of the discipline that has produced it. That discipline’s theories of knowledge shape what new knowledge is produced and define what questions are asked in the search for new knowledge. People within these disciplines are accountable to their professional body and the perception of "quality" is linked to professional control, ie, what is seen as high quality is constrained by that discipline or profession.

By contrast, contemporary knowledge production occurs across disciplines. Here, new knowledge develops from the fertile ground between disciplines. Contemporary knowledge is developed in a context of practical application as opposed to traditional knowledge, which is developed purely for knowledge’s sake with the key driver being the development of expertise. As such, contemporary health and medical knowledge must answer to multiple stakeholders, eg, professionals, patients, funders, society, and different stakeholders may have different expectations. The value of contemporary knowledge is linked to its level of practicality, eg, does it add value to the broad group of stakeholders, is the solution cost-effective, socially acceptable, etc?

The traditional model of knowledge, therefore, produces leadership within disciplines. Leaders are selected on the basis of their individual reputations. Leaders in the different professions use different values and different norms to guide and control. Different professional cultures affect concepts of leadership, eg, in the old triumvirate leadership in health, three cultures could be interpreted: doctors with a culture of "curing"; nurses with a culture of "caring"; and administrators with a culture of "counting". Thus, there is potential for conflict and a clash of cultures, as is referred to in Professor Bryan Parry’s presentation.

The problem with the traditional form of leadership is that it is difficult to co-ordinate different functions and this becomes increasingly difficult in more complex settings. In the leadership model it is also very difficult to achieve accountability to external bodies, eg, funders.

In the contemporary model of knowledge, leaders must build bridges between disciplines, working within a multidisciplinary team and focusing on good working relationships. This type of leadership demands high levels of trust but that trust is built on a different foundation than the old models of professional trust, eg, where a clinician needs to maintain clinical credibility.

Contemporary leadership is built around a "wholeness responsibility" rather than discrete tasks and, thus, all leaders have responsibility for activity throughout the whole organisation.

The Auckland Healthcare manager-clinician partnership model captures many elements of the contemporary knowledge model of leadership but only if the emphasis is on "partnership" leadership rather than clinical leadership.

The shift from traditional to contemporary knowledge production demands a shift in culture. Culture grows in any definable group that has a shared history. The history provides a basis for the group’s tacit beliefs and its culture is perpetuated through practice. Socialisation is the key to building culture, for example, doctors are guided by professional colleagues and learn about being a doctor through interaction with them. This can be a very subtle but powerful process. Culture is reflected in artefacts such as symbols, for example, its language or jargon, and through standard practices. Establishing a new set of standard practices is one way to develop a new culture.

Dialogue is fundamental to bringing about a change in culture. Dialogue gets below the level of debate and provides a process whereby the collective background of thought and meaning can be explored and tacit levels of culture can be examined. Defensive systems must be suspended to allow real dialogue. In the contemporary knowledge model, the leader’s role is to create the conditions where such dialogue can flourish.

[View Ms Simpson’s presentation, Leading when control does not work]

"Leading quality teams in general practice" was a presentation by Dr Peter Jansen, Medical Director, Boehringer Ingelheim (NZ) Ltd, and formerly a director of ProCare Health Ltd, New Zealand’s largest independent practitioner association (IPA).

At ProCare, Jansen was chair of the Quality Committee. He has a background of 14 years in general practice in rural (Whangamata) and urban (South Auckland) settings. He is the Treasurer of Te Ohu Rata o Aotearoa (Te Ora/The Maori Medical Practitioners’ Association) and a Board member of both Quality Health New Zealand Ltd and the MidCentral Hospital and Health Service (HHS). Jansen is of Ngati Tangata (Ngati Raukawa descent).

Jansen reviewed his experience establishing quality practices in general practitioner (GP) teams in ProCare. ProCare was established in 1995 by the amalgamation of three IPAs.

The research basis for the training programme included:
  • The Radford Report, which showed that 80% of patient satisfaction is based on the communication skills of clinicians;
  • Research into GPs’ expectations;
  • Collated requirements of purchasers and national health goals;
  • Overseas models of quality improvement in primary health care.

The resulting "quality framework" is outlined in the Performance Report on Ambulatory Care (ProAC). ProAC includes measurements of performance that:
  • Are important to stakeholders;
  • Are valid, useful and measurable;
  • Use available data;
  • Have the potential to show improvement.

Various dimensions of quality are considered in the report, including patient/service quality, professional/clinical quality and management quality, and these are further subdivided into important attributes within each category.

Each quality programme is reported within ProAC (refer slide 10) for sample report construction). Key performance measurements are identified and goals are set for each quality programme. Measures are weighted, reflecting the perspective of relevant stakeholders, so that achieving all goals will give a score of 100 for each category.

For example the "professional" quality dimension includes programmes grouped as follows:
  • Health Promotion: eg, adult immunisation, smoking cessation, melanoma awareness;
  • Consultation skills: eg, video review of consultations, Maori consultation skills, motivational interviewing;
  • Acute life threatening: eg, CPR;
  • Acute minor: eg, minor surgical skills;
  • Chronic disease: eg, asthma, congestive heart failure, chronic obstructive pulmonary disease;
  • Mental health: pilot underway.

Maori need particular consideration because of, firstly, this group’s ongoing issues of unmet needs and poor access to services, and, secondly, a contractual obligation to this group through the Treaty of Waitangi (the Treaty of Waitangi principles established the Crown’s responsibilities for appropriate and accessible health care for Maori). The "Improving consultation skills with Maori" training programme was the first "big ticket item" tackled by the ProCare Quality Committee. It aimed to provide GPs with new knowledge and skills and to increase their awareness of the communication needs of Maori.

These issues were discussed with cell leaders and agreement was obtained on the need for this course. The educational programme was trialled within three South Auckland cell groups and included:
  • Needs of Maori;
  • Background of Maori health issues;
  • Pronunciation skills.

Analysis showed that many doctors found discussion of the information needs of Maori patients very useful in developing further their own understanding and knowledge of Maori cultural and traditional beliefs. A report on the trial was published and the programme was refined and expanded and marketed to other cells.

Overall, the pilot project achieved its aim of giving basic knowledge and skills to GPs to help them in their practice. There was also indirect evidence of the programme’s success in the results of a survey of prescription presentation rates. This survey of ProCare South doctors, which tracked prescriptions for children over three months, revealed non-presentation rates of 7-23%. The only factor found to affect presentation rates was the identity of the doctor. The highest rates of presentation were of prescriptions from those doctors seen to have good clinical skills and leadership qualities.

[View Dr Jansen’s presentation, Leading quality teams in general practice]