How to Achieve Effective Clinical Engagement and ... · leadership, engagement and team effectiveness, when working across organisational and professional boundaries, particularly

Practical Recommendations

Fran WoodardApril 2007

How to Achieve Effective ClinicalEngagement and Leadership when Working AcrossOrganisational Boundaries

Contents

2

Introduction 3

Aims of the Practical Recommendations 4

Why we need Cross-boundary Working 5

Setting up a Cross-organisational Project 7

The Team 11

Patient Involvement and Leadership 13

Clinical Leadership, Engagement and Team Working – What makes it effective? 17

Incentives 19

Accountability 20

Barriers and Risks 21

Conclusions 23

References 24

We are now listening to patients and serviceusers more than ever before and acting on whatthey tell us to improve the way we work.

There is also a rise in the importance ofpartnership and collaborative working, whereboundaries between and across organisations are being challenged and barriers removed. TheNHS is focusing more on partnership working,collaboration and delivering quality care acrossthe whole patient pathway or journey, with a growing need for more cross-boundary clinical working.

Despite this focus, patients are still having poorexperiences and reduced quality of care whenthey move from one NHS organisation toanother, and from the NHS to social services or the independent and voluntary sectors.

Achieving improvements in services within thecomplex social and organisational environmentof healthcare is extremely challenging. Serviceusers, patients and carers are fundamental to the process of improvement. However, to gainthe full commitment of all partners and tosustain improvements, clinical engagement and leadership is vital.

It is clear that clinical engagement and leadershipis crucial for the ownership and sustainability of service improvements, but organisations often find it is hard to achieve in practice.

These recommendations identify thecharacteristics and impact of high quality clinicalengagement, leadership and team effectivenessacross organisational boundaries. They share theknowledge obtained from working with actualchange projects, and pick out the fundamentalelements that allow clinicians to lead change andmake a real difference to the patient experienceand quality of life.

Introduction

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The NHS is going through a period of rapid transformation,with an increasing focus on the delivery of quality care,centred on the patient.

The change projects aimed to improve the qualityof patient care. They have helped to identify thecharacteristics and impact of high quality clinicalleadership, engagement and team effectiveness,when working across organisational andprofessional boundaries, particularly whenfocusing on the patient journey.

These recommendations aim to pick out the mainelements that facilitate clinicians to lead changeacross organisational boundaries, to describe the basic tools and techniques and explore howthey can be applied. These include contextualfactors, skills and individual behaviours.

It is hoped that this knowledge will provide a foundation for clinicians and managers toconfidently lead more cross-boundary working,thus improving the patient experience.

The key findings are:

■ Clinicians need to lead cross-boundaryworking

■ Change can be successfully achieved byeffective cross-boundary projects and patients benefit

■ Patient and user involvement is crucial to successful cross-boundary working

These recommendations are aimed at frontlineclinicians and managers who want to improve thequality of care for patients across organisationalboundaries. They provide practical information toconsider before and during a cross-organisationalproject, thus helping ensure successful outcomes.Additionally, these recommendations highlight to policy makers the fundamental requirementsfor effective cross-organisational working,partnerships and collaborations.

Aims of the Practical Recommendations

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The recommendations within this practical guide are based on the knowledge gained from actual cross-organisationalchange projects.

In addition, this type of working requires clinicians to develop an enhanced leadership style and skills,particularly emotional intelligence, and effectivecommunication and influencing skills. It is clearfrom the projects examined that these skills are more important when working acrossorganisational and professional boundaries.

The benefits of cross-boundary working include:

Improving the patient journeyCo-ordinating care across the patient journey iscrucial if patients are to have high quality care and good experiences.

Many patients, however, currently highlight thefragmentation, loose connections and poorcommunication between organisations andservices that provide the various elements of their healthcare.

Most complaints about quality arise fromproblems with co-ordination of care, so it is clear that the focus should be on improvingcommunication and working betweenorganisations.

Evidence shows that communication andpartnership working between organisationsimproves the patient journey (NCCSDO, 2005). A clinician working on a cross-organisationalproject reflected:

“So I’ve learnt a huge amount abouthow hospitals work and kidneydoctors and nurses and kidneypatients. And I’d like to think thatthey’ve learnt something about theprimary care perspective. So it’s notjust we get to understand each other’sperspective across, say, primary and secondary care, the very act of working together means we change patient care.”

Improving efficiencyDespite additional funding, the NHS is currentlyseen to be under significant strain, so efficiencygains must be sought. To improve efficiency,organisations need to work differently and moreintelligently. Working across organisationalboundaries makes sense – outcomes can beachieved that would not be feasible for oneindividual or organisation alone and significantefficiencies can be gained.

Partnerships can enhance individual andorganisational success through more effectiveproblem solving, improved adaptation to change,increased efficiency and improved patient care. As one clinician commented:

“I think that we have achieved thingsin a shorter period of time that wouldhave taken a lot longer to achievewithout making it more joined up.”

Why we need Cross-boundary Working

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Evidence shows that working across boundaries and withinnetworks is more effective in delivering the changes neededin the NHS (Goodwin et al, 2004). Clinical leadership andengagement when working in this way, however, is crucialif these changes are to be achieved and sustained.

Cross-organisational working can have substantialfinancial benefits through increased efficiencies,whilst also enhancing and improving patient care,experience and outcomes. For example, it can help achieve targets, reduce length of stay or re-admission rates, reduce waits and queues,increase access, control demand and facilitatepatients being seen in the most appropriatehealthcare setting. Cross-organisational workingenhances the ability of partners to achieve theseaims, which are more ambitious than could besought by one single organisation.

A more personalised serviceThe Department of Health (DH) white paper –“Our Health, Our Care, Our Say” (2006) –promotes giving service users a louder voice todrive service improvements. The paper gives aclear policy direction of developing and promotingpartnership working and focuses on achievingeffective health and social care provision for the public.

Benefits to staff“Health Reform in England: Update andCommissioning Framework” (DH , 2006) highlightsthe benefits for staff as “a greater ability to workcollaboratively across the clinical divides toconstruct care pathways around the individualneeds of patients; and more scope for clinicalleadership and engagement for nurses, midwives,GPs, consultants and other health professionals toshape services.”

Staff involved in inter-organisationalworking have described the benefits as:

■ Better patient outcomes ■ Inspirational – it gives individuals different

and wider perspectives■ Offers more insight into the whole patient

journey■ Offers individuals exposure and prospects

for career development■ Improves personal development■ Improves learning■ Helps with benchmarking■ Provides constructive competition■ Helps individuals learn lessons in a safe

environment■ Offers flexibility to try new things out without

fear of failure■ Enhances communication

Better disease managementPartnership working has become a fundamentalpart of everyday work for many healthcareprofessionals, particularly those working withinchronic disease management, as it has beenshown to deliver better disease management and improved outcomes for patients.

Delivering and sustaining changeAlthough there is currently limited evidence of how partnership working improves serviceprovision, the change projects studieddemonstrate that partnerships do deliver effective changes and fundamentally improvepatient care and experiences.

Why we need Cross-boundary Working

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Senior management support Senior management involvement andcommitment from the top of the organisation isvital for success. Studies have shown that seniormanagement buy-in has the biggest impact onthe progress of clinical service improvements andis critical as a lever for change (NCCSDO, 2006).

Those driving cross-boundary working particularlyneed corporate and senior management support to ensure their work fits in with the widerorganisational strategies.

As with most successful change initiatives, seniormanagement agreement and support enableschange to happen more rapidly. This type ofsupport means obstacles are removed morequickly, as well as ensuring projects are realisticand achievable.

Senior management support means:

■ Staff will feel valued and supported■ Barriers can be removed quickly■ The project is viable from the start■ The project fits in with the organisational

and local health economy strategies■ Change can happen more quickly

“I think it [senior managementsupport] can provide advice aboutwhat’s sensible and what’s notsensible, what’s doable and what’s not doable. And they view the systemin a different way.”

Senior management support can be achieved byensuring the project has senior champions within the different organisations. Agreement from each organisation should be sought and stronggovernance arrangements will help to ensure ongoing senior management commitment and support.

Senior executive involvement One of the key determinants of successful serviceimprovements is the level of interest from theexecutive team.

In order to ensure that leadership is dispersedacross the organisation there also needs to be adesire and capacity for change leadership at bothsenior, executive and clinical service managementlevels. Cross-boundary projects should aim to getinvolvement from a wide range of senior executives.

Robust governance arrangements In order to ensure the success of cross-organisational projects, there must be robustgovernance arrangements in place. This involveshaving boards or steering groups, which haverepresentation from all partner organisations and patients. These boards or groups will ensurethat change projects deliver to time, but also are an essential way of removing barriers andsolving problems.

EnvironmentEstablishing close links and getting to know other staff within the partnership organisations is essential for successfully working acrossorganisational boundaries. The most effectiveprojects have created the right environment to establish these relationships from the start.

A forum to initiate inter-organisational working is recommended, if clinicians are to gain anunderstanding of the different perspectives andworking environments of others. People need tounderstand and explore the different cultures,pressures and issues that affect their colleagues in the various services and organisations.

Spending time on the development ofinterpersonal relationships is crucial whenagreeing cross-organisational objectives for change,and to developing inter-personal and inter-organisational trust. These group opportunities to establish good working relationships are vital to secure a successful project.

Setting up a Cross-organisational Project

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The most successful forums include:

■ Regular face-to-face gatherings It is recommended, however, that these areneutral and open. It is better that they are notowned or dominated by one organisation.

“It’s partly about appreciating thedifferent ways and the differentlimitations that people have to workwithin, that makes you more aware of, you know, how, how people are working.”

■ Team tripsTeams going on trips to discover best practice are useful for getting to know each person’sperspectives, as well as viewing new and different practices.

“And I think things like the tripactually, I mean we all laugh about it, but actually six of us sitting downtogether for a week, I came backunderstanding so much more aboutwhat primary care did. And alsoabout thinking about what X did at X from an equal – you know, I’dbeen a registrar at X but that’s avery particular perspective, it’s notabout how does another hospitalinteract in my sector?”

Patient inclusion on these trips can providealternative perspectives and thus learning, as wellas creating patient champions and increasing themomentum of patient involvement.

Approaches – change management andservice improvement techniques versusrandomised controlled trials

There are many approaches toundertaking cross-boundarytransformational change projects, but themost commonly considered methods are:

■ Patient evidence driving change management ■ Service improvement techniques■ Randomised controlled trials (RCTs)

RCTs tend to be less innovative and creative,particularly when undertaking complex cross-boundary projects. They do not take intoconsideration the complexities of the real world,and take longer to deliver results. Additionally,complex changing political environments make it difficult to evaluate change through RCTs.

When working across boundaries, there is a needto think creatively and innovatively, as well ascritically and scientifically. The culture of cliniciansprimarily using RCTs therefore requires changingand people should begin pushing the boundariesof what is clinically and methodologicallyacceptable, taking risks along the way. Thisrequires a change in the mindset and approachesused. As one patient commented:

“Real patient centred care cannot solelybe delivered within the narrow prism of double blind trials. There is a deep divergence between the goldstandards of patients and doctors forhealthcare. One says ‘double blind’ the other ‘quality of life’. Simply put,clinicians need to have a far moreflexible point of focus especially inrelation to improving quality of life.”


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Evidence suggests that when patients’ insights and perspectives are sought about how care has improved, they are key drivers of change andservice improvements (Care Service ImprovementPartnership, 2006). Therefore the starting point for a cross-boundary project is not “we must doserious research here”, but “we need to improvequality of care”.

Bridging roles Moving away from traditional roles and jobstructures can facilitate transformational change.Creating new roles at the beginning of the project,which, for example, span clinical and managerialtasks can help drive forward change, especiallywhen working across several organisations.

Roles to be considered:

■ Portfolio rolesIt is becoming more common for clinical staffto perform managerial tasks and ‘portfolioroles’ where people work across severaldifferent areas. For example – a GeneralPractitioner (GP) who has a clinical role, is Professional Executive Committee Chair, the primary care lead for modernisation and a clinical champion for a cross-organisationalchange project.

■ Bridging rolesStaff can speed up change by movingbetween managerial and clinical areas, for example – using clinical staff who have developed transformational changemanagement skills can provide uniqueinsights into the synthesis of clinicalprocesses, management and change theories.

■ Boundary spannersPeople who work in the middle groundbetween different organisations or agenciescan act as ‘boundary spanners’ and manageinter-organisational relations. They can co-ordinate activities and bring organisationstogether, taking a neutral position. Their roleas a committed and trusted facilitator helpscreate a successful partnership. For example –network leads and project managers whowork across a whole project.

■ Clinical championsEmbedding clinical champions within achange project can enhance success. Theseroles provide leadership and vision to projects,and can create substantial peer pressure tofacilitate change. There should be a clinicalchampion for each organisation involvedwithin a cross-organisational project. Thisestablishes influence over other clinicianswithin individual organisations, whilst alsopromoting collective working with otherclinical champions to emphasise the wholepathway perspective.

It is also important to consider roles that bridge the patient and healthcare professional gap, thus ensuring meaningful involvement andpartnerships with patients. Bridging this gap is fundamental to securing good outcomes.

Dedicated project management supportEmploying a dedicated, neutral individual oragency to manage the project is recommended.Dedicated project management support leads to better commitment, trust and reliability andhelps stabilise membership across competingprofessions. This is an example of boundaryspanning roles. Project management skills are also fundamental to the success of complex cross-boundary change projects.


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Open communication betweenorganisationsIt is necessary to ensure close links and opencommunication between organisations, and clearmission statements and unambiguous rules ofengagement, especially for change projects that span across secondary and primary care.

In addition, it is recommended that these types of change projects are inclusive – ensuring allagencies and individuals gain ownership of theproject from the inception. A network can be a useful method of formalising opencommunication routes.

Information sharingManaging change projects effectively relies on theability to gather, co-ordinate and evaluate reliableintelligence and information. Good informationtechnology enables professionals to connect and share views, share expertise and effectivelyevaluate projects.

Successful projects involve sharing informationacross organisations and IT links established at thestart of the project facilitate this. People involvedin the change project need to be empowered to share information, which will result in cross-organisational improvements.

Time out and the space to undertakeservice improvement work It is clear that time away from the workplace and the job role to establish relationships andundertake service improvements is invaluable,particularly for clinicians.

Projects that allow people space to think andexplore different ways of working do well. Thistime out is important and should be allowed for,as one clinician emphasised:

“But it’s actually having my head space time that’s been really important for me.”

Allow time Working across organisational boundaries anddifferent professional groups takes time. Projects are often complex to set-up. The set-up period is however essential to future success so the time should be allowed for. It also takes time to establish relationships and trust. Despite this initial investment once the relationships and trust are established, the gains extend beyond the specific pathways or change project.

Sharing the learning A fundamental way of increasing trust andcollaborative working is to ensure all the learningfrom cross-organisational change projects isopenly shared as widely as possible within the health economy. This may require sometranslation of the learning for specific audiences or environments. It is suggested that multiplemethods are used, for example: presentations,workshops, interactive sessions, briefing papers,fact sheets and web based information.

Evaluation of the projectIt is important that ways of measuring andevaluating the success of cross-boundarytransformational projects be considered when setting up the project. Regular robustmeasurement and evaluation must therefore be included as part of the set-up.

Human Resource (HR) support Good HR support is necessary to help with thecreation of new roles and new ways of working.Having active, supportive and innovative HR inputto the project from the beginning will assist inspeedily creating new roles so that people canwork across organisational boundaries.

There is a need, therefore, for HR input to help reduce and/or break down some of thebureaucratic NHS barriers in creating new andinnovative roles and training programmes.


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Leadership skillsClinical leadership and engagement are seen ascentral to the modernisation agenda, but leadingcross-organisational change requires a multitude of skills.

Evidence suggests that clinicians leading thesetypes of projects need, first and foremost, to have excellent interpersonal skills. They must be personable, communicative and respected by their colleagues.

“So, I think you need to have a betterawareness of how you work and howyou interact.”

Successful projects have clinicians whoare able to lead change by:

■ Gaining respect from colleagues■ Being honest, impartial and transparent■ Working beyond any individual or

organisational perspective, boundaries or thinking

■ Providing a clear sense of direction■ Providing a clear and inspirational vision

which pulls everyone together■ Working in equal partnership with patients ■ Constantly focussing the project on patient-

centred outcomes■ Constantly challenging the status quo■ Believing in the project and importance

of inter-organisational working

“I think, you know, it’s because you need to be able to behaveappropriately, influence when youneed to negotiate, when you need tounderstand where other people arecoming from, manage conflict, have astrategy, you know, think a little bitabout structure and process and howyou deliver that, so all of those thingsare essential.”

In addition, the specific skills required by clinicians to lead cross-organisationalchange include:

■ Strong and effective influencing skills■ Good negotiating and conflict

management skills■ A good understanding of structure and process■ Enthusiasm, confidence and belief in

the project■ Empathy and understanding of other

colleagues and their working styles andperspectives

■ An understanding of diversity and thedifferent cultural issues of other organisationsand individuals

■ Excellent communication skills with patients and carers, and an ability to create effectivepartnerships with patients

■ Robust management skills and knowledge – for example financial and business casedevelopment etc

■ The ability to admit to ‘not knowing’

Investment in training, mentoring and coaching can help clinicians to enhance this skill base.Regular personal feedback in a safe andconstructive environment is fundamental to this developmental process.

“Nowhere in your training is theredevelopment of team working skills and behaviours and also they talkabout teams in clinical care, but it’salways like the doctors that aresupposed to be leading the team.”

The Team

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Inter-professional relationships Respect between colleagues involved in theproject is seen as crucial to its success. In order to influence others and promote change, theindividuals involved need to have mutual respect.Good inter-professional relationships are key tocreating the basis for change. One GP, working in a PCT admitted:

“My lever has to be the level of respectthat my colleagues have for me... it’salso about the level of respect youhave for the people you’re workingwith, and they have for you.”

Collective or dispersed leadership There is increasing evidence to suggest thateffective change projects depend on collective ordispersed leadership, as it has been shown thathierarchical leadership does not work in thesesettings (NCCSDO, 2006).

Collective or dispersed leadership offers furtherpotential for change and can be more receptiveand proactive in change projects.

Collective or dispersed leadership is a move awayfrom traditional hierarchical leadership towardsshared leadership between leaders and followersand different leadership groups. It is characterised by a shared understanding of what leadership is in the specific context, and a commitment toshared goals and values. Collective or dispersedleadership is seen to offer a flexible and adaptableapproach, identifying the strongest leaders forparticular projects or areas of work. It builds oncollaboration and uses all the expertise and skillacross a group.

The Team

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A Healthcare Commission report (2005)commented that despite recent attention ‘thehealth service could still often seem to bedesigned around the needs of NHS staff ratherthan patients’. There is a real requirement tochange the situation as Derek Wanless (2002)proposes ‘putting patients in control and helpingthem to be fully engaged in their healthcare islikely to be more cost effective and offer bettervalue for money than if people are simply passiverecipients of services’.

To be truly patient-centred, the patient voice andexperience should be used to shape the future ofthe service. Information from patients or serviceusers can stimulate and drive change. It is clearfrom successful projects that their comments andviews can bring a unique perspective, helpingpeople challenge the way they and others work.As a patient commented:

“So I think that was a forum in whichthe patient voice really got heard. I mean profoundly heard and gotwritten up, and delivered outcomes.”

To initiate effective patient and userinvolvement it is recommended that you:

■ Get patients and service users involved fromthe beginning

■ Have a clear idea of why you are involvingthem and your aims, before you invite them

■ Equip them with the training, informationand skills required

■ Be willing to embrace their ideas and views■ Be prepared to be challenged (the

professional view is not always right)■ Be prepared to sometimes feel uncomfortable ■ Begin to see things through the patients’

eyes by seeing their view of the world, theirperspectives and priorities and issues affectingtheir quality of life

■ Involve patients around a specific well definedarea rather than the whole pathway

■ Develop patient champions who have a widerange of experience, can develop rapport withclinicians, are visible and can keep the focus on patient centred care and outcomes

Patient Involvement and Leadership

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Meaningful patient involvement is critical to successful inter-organisational working. Evidence suggests thatclinicians who are motivated by patient involvement and leadership improve their patients’ quality of life on the patient pathway (NCCSDO, 2002).

Patient involvement from an early stage will:

■ Highlight the gaps between services in a unique way

■ Challenge existing practices and deeply held views

■ Bring new perspectives■ Drive forward improvements■ Influence others to buy into the change process■ Be a powerful force for change at clinical and

organisational levels

We should not underestimate the power ofpatient and user involvement. The voice ofpatients and the evidence they provide isextremely influential and can speed up the changeprocess. It is important to move beyond purepatient feedback, to true patient involvement andpartnerships, as these will facilitate substantialtransformation of the NHS and deliver dramaticquality of life improvements for patients. For a project to be successful it is clear, however,that patient involvement must be meaningful.Clinicians have to take notice of patients’perspectives and act on their suggestions. A clinician reflecting on the experience of a change project reflected:

“But they wouldn’t have learnt unlessthey’d seen what they said made adifference. And I think that’s reallyimportant, it’s not token, if we getpatients involved, then it’s our duty, as clinicians, to work really hard to dothe things that they want us to do.”

Meaningful patient involvement includes:

■ Providing patients with the right informationand background on the project and helpingthem understand the aims of the project

■ Giving them time to get to know the service and staff

■ Continuous patient feedback throughout theproject – don’t just stop when users’ viewshave been obtained

■ Patients being involved at every stage of theproject as part of the project infrastructure

■ Gaining patients’ views on both currentservice provision and new models of care

■ Using patients to evaluate services (andpaying them to do it which can challenge the traditional relationship between a patientand provider by creating a direct line ofaccountability between them)

■ Patients offering peer support to each other■ Using patients to teach clinical staff■ Taking patients on good practice visits to gain

the patient perspective as well as the clinicalor managerial one

■ Acting on patient feedback and doing whatthey want you to do


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Empowerment of patients Patients who feel empowered to share their views and believe they are going to make a real difference drive successful projects. It is theresponsibility of the project team to make patientsfeel very involved. Only when patients and usersfeel completely empowered can they begin to have a real impact on the changes.

The project has to focus on what will affectpatients’ everyday quality of life. Patients have to live with their conditions or diseases all of the time and therefore the focus should be onimproving their quality of life. This is seen as oneof the most motivating factors for both patientsand clinicians. For example, as one projectmember explained:

“We did some work around a newhealth centre. And we did this bigneeds analysis with people on the twolocal estates. And what they wantedwas a health visitor locally and afemale GP. That was it, that’s all theywanted. A year later, we did the sameexercise. They wanted a communitygarden, an IT suite, a housing office in the building, benefits adviser, amental health suite and key workerhousing. And the reason they wentfrom one to the other was they were empowered.”

Empowering patients involves:

■ Giving them time to understand the serviceand ask the right questions

■ Choosing patients with the right skills and equipping them with the informationthey need

■ Acknowledging the patients’ perspectives■ Acting on patients’ inputs ■ Feeding back to patients and acknowledging

the impact they have made

Patients are clear that quality of life should be thefundamental driver for changes to healthcare. It isimportant not to underestimate the impact thiscan have on healthcare outcomes and economics,for example increasing self-care and self-management. Additionally, there can be asignificant gain to the national economy by, forexample, getting people back to work, reducingsickness absence etc.


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Equal partnershipsWorking together with patients and users in a partnership is the key to successful patient and user involvement. It is recommended that clinicians support patients, helping themunderstand the system and create aspirational but realistic plans for change. However, it isimportant to note that patient centred care andequal partnerships can only deliver real change if the clinician has effective interpersonal skills, an ability to listen and strong emotionalintelligence characteristics.

Seeing things from a patient’s point of view is animportant skill, and having a strong partnershipwith patients and users helps people achieve this.

Described by Pete Fleischmann (Fletcher andBradburn, 2001) as: “a way of changing thephilosophy of an organisation and all the roles within it”, user involvement may be difficult anduncomfortable at times, but, he adds, “if it is done right, it will result in a better service.”

A clinician commented:

“I view the world through patients’eyes – wearing patient tintedspectacles! And I’m happy to rock theboat in terms of how we work andwhat we do, because I believe thereare benefits to patients.”

And one patient described equal partnership asthe best part of their patient involvement activity:

“For me as a patient the mostimportant part is actually me feeling a genuine partner and a genuineinsider.”

Patient and user involvement must not be seen as a bolt-on activity. It has to be meaningful andempowering for those involved.

Training The most successful patient and user involvementprojects use training as a tool for both staff and users.

Those involved in the project need to understandthe various change management andorganisational development techniques, such as: demand and capacity, management of flow,human dynamics of change, etc.

■ Patient and user trainingPatients and users invited to take part in theproject need to have the relevant skills and so training is recommended to enable themto undertake the activities

■ Staff trainingStaff require training to help them appreciatehow and why patients and users can becomeinvolved

■ Patients and users training staffSome projects have successfully involvedpatients and users in training staff


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■ Individual interestOne of the most important factors was foundto be people’s willingness to work on theproject. The most successful projects involveclinicians who have self-selected because of their passion and interest in the area.

■ Experience and seniorityHaving the relevant experience and seniority is necessary in order to generate respect andcredibility across organisations. Successfulprojects have leaders who generate and build trust, as well as influence at all levels.

■ Close links with managementBeing able to work closely and effectively withthe appropriate level of management is seenas important. In addition, clinicians often have a deep historical knowledge of theorganisation they work in, compared to managers who may move roles morefrequently. A member of the team stated:

“The way you get really radicalchange is by managers and cliniciansworking properly together.”

Clinical Leadership, Engagement andTeam Working – What makes it effective?Evidence suggests that effective clinical leadership,engagement and team working requires many different elements.

■ Political awareness and team workingWorking successfully across organisationalboundaries requires a good level of politicalawareness and an ability to work as a team. It is worth being mindful that current medicaltraining does not usually focus on politicalawareness and team working, so doctors mayhave to find ways to enhance these skills to be able to lead teams effectively whenworking within the complexity of cross-organisational projects.

■ IT infrastructure and supportTechnological support for the project isrequired and is recommended for teamworking and leadership. The power of data in creating peer review and competition hasbeen seen as an essential lever for change.

Training and development Individual training and team development are seen as key elements in effective clinicalleadership. Understanding the techniques involvedin change management is important and trainingof this type is available from many organisations.Enhancing awareness of the behavioural elementsof change management is also essential.

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Portfolio rolesEvidence demonstrates that successful clinical leaderslook to others for support and it may be necessary toappoint other key leadership roles within the project.

■ Respected professional leadersIt is suggested that the project team alsoengages respected professional leaders whowill promote the project to peers and acrossthe organisation. These people are, ideally,professional or clinical leaders with asignificant level of charisma, respect andstanding. Less senior or less well respectedmanagers are seen as generally possessingless kudos and leverage.

■ Boundary spanners‘Boundary spanners’ are people who workbetween different agencies, with the job ofmanaging inter-organisational relations. It may be necessary to appoint a ‘boundary spanner’ tocoordinate activities and provide cohesion. Theirrole may not be dependent on status, but on theirskill as committed, reliable and trusted facilitators,with expert relationship management skills.

Clinical Leadership, Engagement and Team Working – What makes it effective?

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It is important to gain measurable outcomes forcross-organisational projects. Nowadays, manynational targets are shared between two or moreorganisations and these targets can be achievedmore effectively by organisations working closelytogether across their organisational boundaries.

Patient needThe key incentive is seen as improving thepatient’s experience across patient pathways. Thereality is that patients experience a fragmentedservice as they move between differentorganisations and from primary to secondary care. If the service is to be truly patient-centred,improving this experience must be thefundamental driver for change. The involvementof patients and hearing their perspectives,therefore, strengthens this drive for change.

Personal learning and developmentThose involved in inter-organisational projects gain considerable experience. It is recognised thatpersonal learning and development is an incentivefor clinicians to get involved. Junior medical staffsay that being involved dramatically widened theirperspective both of the health service and ofworking with patients and the local population.One junior medical consultant commented:

“It’s given me a very useful, very goodand strong focus at an early stage inmy consultant career, to allow me todevelop myself and to develop morebroadly, I think, than I would havedone without it, you know, muchstronger sense of working withpatients, and for patients in a positiveway, not just the individual patient,but actually the patient population.And I think I have a much better senseof what happens in general practice…”

Improved quality and efficiency in healthcare deliveryThere is ample evidence that working acrossorganisational boundaries improves quality of life for patients, and achieves better utilisation of healthcare resources (Goodwin et al, 2004).

Locally agreed incentives through contracts or local agreements (e.g. Quality OutcomeFrameworks, pharmacy contract, consultantcontract) can be used as levers to promote cross-organisational working.

It is crucial that commissioners view the wholepatient pathway, not individual sections, and alignappropriate incentives to enhance the quality ofcare provided. Early involvement and engagementwith local commissioners of services is vital toensure long term sustainability is achieved.

Incentives

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Incentives across the healthcare system are seen as vital to achieving and sustaining change. It is recognised,however, that there is a lack of cross-organisationalincentives, despite many policies citing this type ofworking as fundamental for the modernisation and radical redesign of healthcare.

Clinicians working across organisations and staffin boundary spanning roles frequently experiencethe bureaucracy of individual organisations. Forsuccessful cross-organisational working to occur,there is a need for new, innovative accountabilitymechanisms. As a clinician commented:

“I think that is critical, because for as long as people are employed bydifferent Trusts, then obviously, youknow, your allegiance primarily has got to be to the person who pays your salary.”

Being accountable to different organisationsmakes this type of working very time consuming.Often simple ratification processes across manyorganisations can slow down a project and stifleor prevent innovation. For example, in a largecross-organisational project, the attempt to getsimple protocols agreed originally took over ayear. By putting into place a new mechanism forcollective agreement and ratification (medicaldirectors from each organisation ratifying cross-organisational policies and protocols), changes topractice, policies or protocols could be achievedwithin a month.

Innovative human resource practice could help tocreate new accountability mechanisms, reducingbureaucracy, but still ensuring all legal andstatutory requirements are fulfilled. For instance,creating flexible effective honorary contractmechanisms, having a process where new rolescan be assessed and banded speedily by expertswith human resources and improvement scienceknowledge, and creating flexible working practicescould all enhance cross-boundary working.

Accountability

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Being employed by different organisations and havingsplit loyalties is considered one of the main barriers tointer-organisational working. A change in this culture isfundamental to successful cross-organisational working.

The main barriers to inter-organisationalworking are seen to be:

■ Lack of full senior management support andcorporate buy-in

■ Financial pressures of, and between, differentorganisations

■ Lack of alignment of clinical, financial andmanagerial perspectives

■ Bureaucracy ■ Lack of systems in place to communicate

across organisations (including robust IT links)■ Individual anxieties of going into the

unknown – “it all feels a bit risky”

Clinical autonomyAnother potential barrier is clinical autonomy. It is important to understand how cliniciansperceive their accountability in relation to clinicalautonomy, and the potential implications whenworking across organisational boundaries.

It is important to understand what drives anindividual doctor, as only then can you try to align these motivators to the project aims. The likelihood of success will be enhanced byattempting proactively to align accountability and clinical autonomy to the aims and outcomesof cross-boundary projects.

Breaking down the barriersBy examining the barriers and risks it is possible to identify solutions to reduce these barriers.

■ Case studies / patient storiesUsing case studies and patient stories of howworking across organisational boundaries hasbeen successful in helping to achieve dramaticimprovements to the quality of patients’ lives,can slowly break down barriers.

■ Reframe financial constraintsResearch suggests that finances are not alwaysfundamental to change. A change in perspectivelinked to working in different ways is often themost effective mechanism to achieve change. Thisdoes not necessarily require significant resources.

“It’s looking at things in a slightlydifferent way and approaching theproblem of making changes happen ina way that sees a different time frameand different goals – because actuallysome of the things that we’re tryingto do don’t cost any less, don’t costany more, but they dramaticallyimprove things for patients andprobably for staff as well.”

Barriers and Risks

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Personal risksWorking across organisational boundaries andredesigning the patient pathway across theseboundaries can also result in many personal risksand uncertainties.

“So I suppose there’s a disruption to your planned future, which is youknow, which makes you feel a little bit nervous.”

The way staff currently work will be challengedand many will start to feel uncomfortable. Theremay be changes to roles, places of work anduncertainties around posts, as well as changes inthe way people are managed. Potential job lossesor significant changes to job roles may be part of this type of change. Departments and servicesmay be destabilised during the process, causingpersonal anxiety. These are all real risks, whichmust be considered and actively managed.

Going into the unknown can be extremelyunsettling. Starting with a blank sheet of paper toredesign the patient pathway across organisationsis exciting, but there will be staff who arefrightened of the outcomes.

“I think it’s quite risky, becauseobviously a percentage of us aregoing to have to change job roles.That’s the worst outcome for us I suppose.”

This uncertainty amongst staff can reducecollaboration and cross-organisational working bydestabilising the existing working of departments.

“A lot of people feel that their jobs are much less stable than they were,which tends to mitigate against beingcollaborative and, in general, more of a bunker mentality.”

Whilst the above personal feelings should not be ignored, the studies also revealed that manypeople involved in the projects felt there weremore opportunities than risks.

Breaking down these personal risks involves:

■ Getting everyone involved■ Creating a culture in which everyone can

influence the future■ Understanding and acknowledging the

individual personal risks and challenges■ Identifying the significant personal

development opportunities■ Identifying and keeping a focus on the

benefits for patients■ Identifying clinical and patient champions

Barriers and Risks

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These Practical Recommendations have aimed to fill the current knowledge gap around what is required for good clinical engagement andleadership when working across organisationalboundaries. It aims to be a useful source ofinformation for front-line practitioners, offeringnew knowledge and evidence for clinicians andmanagers to consider when embarking on a cross-organisational project.

The key findings are:

■ Clinicians need to lead cross-boundaryorganisational working – but they have to be equipped with the necessary skills andsupport to do this

■ Patients will benefit from effective cross-organisational working and theseimprovements will act as an incentive

■ Patient and user involvement is crucial to successful cross-boundary working

■ Moves to align appropriate incentives andcreate new innovative accountability lines are needed for projects to succeed

■ Rapid consideration must be given to thecurrent and future training of doctors andother clinicians to enhance their effectiveparticipation in inter-organisational working

Conclusions

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It is clear that collaboration, partnerships and cross-organisational working is the way forward. This type ofworking is crucial for the delivery of high quality, wholepatient pathway care.

Other literature used includes:

Alimo-Metcalfe, B. Alban-Metcalfe, J. (2004). ‘The Myths and Morality of Leadership in the NHS’Clinicians in Management. 12.

Audet, A. Doty, M. Shamasdin, J. Schoenbaum, S.(2005). ‘Physicians’ Views on Quality of CareFindings’ Commonwealth Fund National Survey of Physicians and Quality of Care. New York: TheCommonwealth Fund.

Bate SP, Robert G. (2006). ‘Experience-basedDesign: from Redesigning the System around thePatient to Co-designing Services with the Patient’Quality and Safety in Health Care. 15(5): 307-310.

Care Service Improvement Partnership. (2004).‘Whole Systems Working. A Guide and DiscussionPaper’ London: Stationery Office.

Care Service Improvement Partnership. (2006).‘Strengthening Service User and CarerInvolvement: A Guide for Partnership. A DiscussionPaper’ London: Stationery Office.

Department of Health. (2006). ‘Health Reform inEngland: Update and Commissioning Framework’London: Stationery Office.

Department of Health. (2005). ‘Health Reform in England: Update and Next Steps’ London:Stationery Office.

Department of Health. (2004). ‘Improving ChronicDisease Management’ London: Stationery Office.

Department of Health. (2005). ‘The NationalService Framework for Long-term Conditions’London: Stationery Office.

Department of Health. (2000). ‘The NHS Plan’London: Stationery Office.

Department of Health. (2006). ‘Our Health, OurCare, Our Say: a New Direction for CommunityServices’ London: Stationery Office.

Fletcher, G. Bradburn, L. (2001). ‘Voices in ActionResource Book. Training and Support for UserRepresentatives in the Health Service’ London:College of Health.

Goodwin, N. Perri, T. Peck, E. Freeman, T. Posaner, S.(2004). ‘Managing Across Diverse Networks ofCare: Lessons from Other Sectors. Report to theNCCSDO’ London: NCCSDO.

Goleman, D. (1999). ‘Working with EmotionalIntelligence’ London: Bloomsbury Publishing.

Ham, C. (2003). ‘Improving the Performance ofHealth Services: The Role of Clinical Leadership’[On-line]. Lancet 25th March.

Healthcare Commission. (2005). ’Despiteimprovements NHS still falls short on puttingpatients first’www.healthcarecommission.org.uk/newsandevents/pressreleases.cfm/cit_id/2008/FAArea1/customWidgets.content_view_1/usecache/false.

References

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These recommendations are based on the findings of real inter-organisational projects carried out across four NHS organisations and the private and voluntary sectors in southeast London. For more information please refer to www.modernisation-initiative.net.

Improving Leaders Guides. (2003). ‘Process andSystems Thinking’www.wise.nhs.uk/cmsWISE/Tools+and+Techniques/ILG/processandsystems/processandsystems.htm.

Institute of Medicine. (2003). ‘Crossing the QualityChasm: A New Healthcare System for the 21stCentury’ National Academies Press: Washington DC.

Integrated Care Network (2004). ‘Bringing theNHS and Local Government Together: IntegratedWorking: A Guide’www.integratedcarenetwork.gov.uk.

Lles, V. Cranfield, S. (2004). ‘Developing ChangeManagement Skills’ London: NCCSDO.

NCCSDO. (2006). ‘Achieving High Performance inHealth Care Systems: The Impact and Influence ofOrganisational Arrangements’ London: NCCSDO.

NCCSDO. (2006). ‘Change Management -Managing Change and Role Enactment in theProfessionalized Organisation’ London: NCCSDO.

NCCSDO. (2004). ‘How Managers can help UsersBring about Change in the NHS’ London: NCCSDO.

NCCSDO. (2005). ‘Key Lessons for NetworkManagement in Healthcare’ London: NCCSDO.

NCCSDO. (2006). ‘Making Change Happen in the NHS: Clinical and Management Task’ London: NCCSDO.

NCCSDO. (2005). ‘Organisational Factors andPerformance: A Review of the Literature’ London: NCCSDO.

NCCSDO. (2002). ‘User and Carer Involvement inChange Management in a Mental Health Context:Review of the Literature’ London: NCCSDO.

Shortell, S. (1998). ‘Assessing the Impact ofContinuous Quality Improvement on ClinicalPractice: What Will it Take to Accelerate Progress?’Millbank Quarterly. Vol 76, (4), p593-624.

Shortell, S. (2002). ‘Developing Individual Leadersis not Enough’ Journal Health Service Researchand Policy. 7, (4), p193-194.

Shortell, M. Marsteller, J. Lin, M. Pearson, M. Wu,S. Mendel, P. Cretin, S. Rosen, M. (2004). ‘The Roleof Perceived Team Effectiveness in ImprovingChronic Illness Care’ Medical Care. 42, (11),p1040-1048.

Spurgeon, P. (2001). ‘Involving Clinicians inManagement: A Challenge of Perspective’ [On-line]. Healthcare Care Informatics Review. Vol. 5, (4).

Wanless D. (2002). ‘Securing Our Future Health: Taking A Long-Term View.’ www.hm-treasury.gov.uk/consultations_and_legislation/wanless/consult_wanless_final.cfm.

Womack, J. Jones, T. (2005). ‘Lean Solutions’ New York: Free Press.

References

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www.modernisation-initiative.net

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How to Achieve Effective Clinical Engagement and ... · leadership, engagement and team effectiveness, when working across organisational and professional boundaries, particularly