Leading Health Organisations in New Zealand - Part 2

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The Benefits of Encouraging Clinicians Into Management and Leadership Roles
The job of manager or leader in the contemporary healthcare organisation has been described under a variety of rubrics. The term modernisation is used in England along with the term clinical governance. Irrespective of the language used, contemporary health sector managers and leaders are expected to engage in quality improvement (including measuring what they do), improving outcomes for patients and risk management. Four themes run through most approaches to understanding what it means to manage and lead in the health sector today:

1. Clinicians need to accept that clinical decisions are also resource decisions while managers need to accept that resource decisions impact on clinical domains.
2. Multidisciplinary teams not individuals will increasingly be identified as the primary unit of service delivery.
3. Professional autonomy will be accompanied by a willingness on the part of clinicians to accept transparent accountability systems.
4. Clinical work will become increasingly systematised and its outcomes will be scrutinised.^{[ 11 ]}

As these propositions become accepted realities in the contemporary health environment, it will become even more apparent that clinicians will be required to take a major stake in health leadership. Research undertaken in Australia, New Zealand and the United Kingdom over the past few years suggests that medical clinicians as a group reject multidisciplinary teams, transparent accountability systems and efforts to introduce control systems into clinical practice. ^{[ 5 ] [ d ]} This raises challenges yet securing clinicians in leadership roles will provide the health sector with a vital opportunity to get both buy-in and a chance at control. It will not be possible to implement any prescription for health service delivery encompassing contemporary management agendas without identifying clinicians as central to leadership. I need to note here that a colleague who critically reviewed this paper pointed out that Degeling’s research in New Zealand is five years old now and, in his opinion, there are increasing numbers of clinicians who strongly support multidisciplinary teams and transparent accountability.

The Need for Leadership Development Across All Levels in the Sector
Nobody would expect to see the following advertisement^{[ e ]} appear in the situations vacant section of their daily newspaper:

It is absurd to think of people at any level in contemporary organisations where their leadership ability is not sought. Because this ability is required at all levels, the sort of people in positions of authority in health care organisations need to be able to bring the best out of the workforce irrespective of the seniority of its members.

Henry Mintzberg^{[ f ]} has described the contemporary leadership challenge facing the health sector in the following terms:

. . . the health system doesn’t need "bosses" or a "professional" style of managing; it needs a craft style, more akin to care than cure. In choosing managers, the system doesn’t need categories (ie, representatives of nurses or doctors etc) it needs leaders. . . in the clinics, within the hospitals, across society, we need more informed community, more nuanced control, more connected cure, and more fortified care – working together. ^{[ 13 ]}

If we accept this position, then it follows that leaders are required across all disciplines and at all levels in health organisations. There are places where this is happening in New Zealand. In Auckland, the Waitemata DHB is working at building trust and breaking down professional barriers with interesting results. For example, it can demonstrate reductions in the caesarean section rates (LSCS) while the national average is increasing^{[ g ]}. Through its investment in facilitated workshops it is achieving new levels of co-operation and understanding between groups such as midwives, obstetricians and anaesthetists.^{[ 14 ]}

The Critical Role of Trust in Healthcare Organisations
Multidisciplinary activity such as that referred to above can only be sustained in an environment of trust. It is critical if leaders are to emerge at all levels. David Clarke, a previous CEO of the large state-owned health system in South Auckland put it this way:

. . . you are only going to make improvements if you change clinical behavior, to change clinical behavior you have to create trust . . . for trust you have to incorporate the team and have judgment and integrity and of course you have to operate with social responsibility.^{[ 12 ]}

Trust is of critical importance in healthcare organisations which are governed by people with political and state sector interests. Not only is this the case because there is disagreement concerning how publicly owned health organisations should be meeting their goals but because resource allocation decisions can be manipulated by politicians and clinicians know it.

The Impact of Leadership on Retention and Recruitment
In this paper, the position has been advanced that processes and systems are the business of management while it is people (not processes and systems) who are led. Consequently, I have looked to recent health management rather than leadership initiatives for an insight into what can be done within organisational settings to improve retention and recruitment.

Hospitals that excel in recruiting and retaining staff have been described in the North American literature as "magnet hospitals". The characteristics of "magnet hospitals" are set out in Table 1.

Table 1: Characteristics of Magnet hospitals

An examination of the key characteristics of magnet hospitals discloses that their hallmark is excellent human resource management. Strong and well directed administrative systems, advancement of professional practice and initiatives in support of professional development were all highlighted in a recent HWAC paper on high performing organisations.^{[ 15 ]} I consequently argue that it is good management, not leadership, that can advance the objectives of magnet hospitals.

However, I accept that the above is an oversimplification. A crucial role of managerial leadership is in ensuring that appropriate structures and processes are in place to support important organisational activity at all levels. Managers who are leaders create and use systems as well as lead people.

A large UK National Health Service study of nurses and allied health professionals identified some important additional factors which contextualised for the New Zealand health system are:

• realistic job previews 
• promoting the reputation of working for the health system in New Zealand
• job security 
• publicising staffing increases 
• increasing staffing levels 
• publicising pay levels where these are attractive 
• raising the profile of non-medical and non-nursing professions.

The items in the list above relate either to human resource management or external relations. Strong human resource management is a prerequisite to improving retention and recruitment of a motivated workforce.

There will be those who say that we have reduced the motivating factors to the lowest common denominator – staffing levels, pay and good human resource management. However, there is more to it than that.


Conclusion
Key points raised in this paper are:

1. Leaders are required at all levels in organisations if they are to change or adapt to the external environment.
2. The characteristics of effective managers are similar to those of transformational leaders. The most obvious is that leaders focus on their people rather than the tasks they perform. 
3. The workplace can be structured and organised in such a way that it can nurture leaders and leadership. 
4. Clinicians need to be encouraged into leadership roles possibly through clinical governance. 
5. Improving retention and recruitment will benefit from interventions largely under the umbrella of human resource management.
6. The relationship between leadership (the way it has been described and discussed in this paper) and retention/recruitment is tenuous. However, there is enormous potential for leadership to positively support healthy workplace environments.

From the above, I contend that:
Clinical staff of all descriptions will feel more satisfied at work if they can see themselves as leaders contributing to positive changes. Staff who feel connected to their organisation and to the health system are more likely to be retained in employment. Workers who believe that leaders listen to their input and communicate with them regarding the continuously changing external environment will feel valued. And finally, satisfied, connected and valued staff will act as magnets for further recruitment into the New Zealand health care system.


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References

1. HWAC. The New Zealand health workforce: a stocktake of issues and capacity. Wellington, New Zealand: Health Workforce Advisory Committee; 2001. Available via the Internet at (http://www.hwac.govt.nz/stocktakereport/stocktakereport.htm) 
2. Kotter J. Leading change – why transformation efforts fail. Harv Bus Rev. 1995 (March–April); 59–67. 
3. Stace D, Dunphy D. Beyond the boundaries. Roseville, NSW: McGraw-Hill; 1994.
4. Drucker, P. Foreword. In: Hesselbein F, Goldsmith M, Beckhard R, eds. The leader of the future – new visions, strategies, and practices for the next era. San Francisco: Jossey Bass; 1996:xi–xv.
5. Degeling P, Sage D, Kennedy J, Perkins R, Zhang K. A comparison of the impact of hospital reform on medical subcultures in some Australian and New Zealand hospitals. Aust Health Rev. 1999; 22(4). 
6. Bass B M. Bass & Stogdill’s handbook of leadership: theory, research, & managerial applications. 3rd Edition. New York: The Free Press; 1990.
7. Drucker, P. The Effective Executive. London: Heinemann; 1967. 
8. Pawar, B, Eastman. K. The Nature and implications of contextual influences on transformational leadership: A conceptual examination. Acad Manage Rev. 1997; 22(1):80–108. 
9. Mathews, L. Leadership and change within New Zealand mental health services.An unpublished dissertation for Royal Australia and New Zealand College of Psychiatrists Fellowship; 1999.
10. Garvin DA. Building a learning organization. Harv Bus Rev. 1993; 96 (1):19–28.
11. Degeling P, Maxwell S, Kennedy J, Coyle B. Medicine, management, and modernisation: a "danse macabre"? BMJ. 2003; 22 Mar: 326:649–-652.
12.  Perkins RJ. Transcript of PhD interview with David Clarke, CEO South Auckland Health.) 1998.
13. Mintzberg, H. The challenge of management in health services. Statement made in the First Plenary Session at the Third International Conference on the Scientific Basis on Health Services. Toronto, Canada; 1999.
14. Youngson R, Wimbrow T, Stacey T. A crisis in maternity services: the courage to be wrong. Qual Saf Health Care qc8615 Module 6 20/10/03 13:35:30 Topics: 219; 383
15. HWAC. A review of high performing organizations. A paper prepared for the Health Workforce Advisory Committee. Wellington, New Zealand; 2004. Available from HWAC, C/- Ministry of Health, Wellington, New Zealand

Further reading on transformational leadership http://www.shef.ac.uk/~iwp/publications/whatis/transformational.pdf