Photo – landscape with ECC

Leadership in Challenging Times

Dr Gareth Goodier

Chief Executive August 2013

What is Leadership?“A leader is the man who has the

ability to get other people to do what they don’t want to do, and like it”

- Harry S. Truman

Harry S. Truman, American President 1945 - 1953

“Leadership the art of getting someone else to do something you want done because he wants to do it”

General Eisenhower meeting with paratroopers of the 101st Airborne Division, June 5, 1944

“A leader is a person with a magnet in his heart and a compass in his head”

- Robert Townsend

“Leadership is the capacity to translate vision into reality”

- Warren G. Bennis

What is Leadership?

What are difficult times?

The last three years at Cambridge:

•Relative reduction of budget >5% p.a. for that period 2009-2012•Stringent monitoring of hospitals with penalties for poor performance

The Evidence! Winner of Acute Healthcare Organisation

of the Year in HSJ Awards (2008) Dr Foster patient safety review scored

99.3/100, the only FT in EoE to get the top ‘band 5’ rating (Dec 2009)

Top hospital in Sunday Times ‘Best Places to work in the Public Sector’ (March 2010)

Joint 1st in for HSMR (RR 64.3) (Feb 2011) Dr Foster “Trust of the year” for

Midlands/East of England – based upon patient experience feedback and two measures of standarised mortality (NSMAR and SHMI)

Dr Foster “Hospital of the year” 2012 -based upon four measures of mortality and 13 measures of clinical efficiency

What did we do?

• Strategic Decisions:– Formed Shelford Group– BI Tool development– EMR business case development– New clinically devolved leadership– Focus upon quality

What did we do?• Formed Shelford Group• Group of England’s leading academic teaching

hospitals based on 18 measures of clinical quality, Research and Development, budget size, Foundation Trust status etc

• University Hospitals Birmingham NHS Foundation Trust• University College London Hospitals NHS foundation (UCLH)• Sheffield Teaching Hospitals NHS Foundation Trust• Oxford University Hospitals NHS Trust (OUH)• Newcastle-Upon-Tyne Hospitals NHS Foundation Trust• King’s College Hospital NHS Foundation Trust• Imperial College Healthcare NHS Trust• Guy’s and St Thomas’ NHS Foundation Trust• Central Manchester University Hospital NHS Foundation Trust

(CMFT)• Cambridge University Hospitals NHS Foundation Trust (CUH)

• Lobbied UK Government Ministers (Treasury, Business, Innovation & Skills, Tertiary Education, Monitor, Department of Health) for increased tariff for tertiary level hospitals

• Benchmarked performance• Compared savings plans • Shared ideas• Variation of Care – using information to reduce

undesirable clinical variation at the level of the team and the individual medical consultant on such things as LOS (including day Rx), utilisation of diagnostics, theatre time, use of medications, harm prevention, hand hygiene etc

What did we do?

What did we do?1. Nursing Productivity

2. Medical Productivity

3. Workforce Transformation

4. Portfolio Strategy

5. Recording Care

6. Variation of Care

7. Patient Flow

8. Utilisation of IS

9. Drugs

10. Procurement & Supply Chain

CUH embarked on a 3 – 5 year process of transformation through which operational improvements lead to step changes that were sustained and enhanced by a major upgrade in technology.

Nursing Productivity

• Ensuring optimal use of the skills and time of nurses and midwives

Medical Productivity

• Making optimal use of the medical team skills and time

• Outpatient Department patients per EFT

• Operation mins per EFT (Surgery)• Discharges per EFT• HSMR by specialty

Workforce Transformation

• Ensuring clinically devolved organisation structure

• Who does what?

• Medical leadership

Portfolio Strategy

• Identifying which services should be developed, where and with whom they should be provided, and which services could be run by others

• “Profit and loss” by procedure code

Recording Care

• Improving quality of clinical records and coding, as well as ensuring the processes are in place for the hospital to be paid for the care delivered

• All observations and evidence suggest that at best there is a TWO to THREE fold variance in clinical behaviour/treatment practice across medicine.

• Where there is poor clinical evidence (e.g. ADHD) the variation increases to a TWENTY fold difference

Variation of Care

“The most expensive item in the hospital is the Doctor’s pen”

Clinical Variation In Cardiologists

0

10

20

30

40

50

60

A B C D E F G H I J K L M N

Cardiologist

% A

bn

orm

al

Opinions of 14 Cardiologists on theabnormality of 38 post-exercise ECGs

Variation In Treatment

Coronary revascularisation procedures,per 100 000 population, 2004

Clinical Variation In Revascularisation Coronary

Cataract Surgeries

Clinical Variation In CataractsConsultant Day Case

Rate % July 07Day Case Rate % July 08

1 83 100

2 91 96

3 26 37

4 80 96

5 83 100

6 82 99

7 79 98

8 59 93

9 96 100

Total 70% 95%

Clinical Variation• A 23- fold difference in the rate at which children in different parts of

England are

• prescribed Ritalin to control behaviour…

PCT Prescriptions dispensed per 1,000 children

Wirral 144

Isle of Wight 107

Great Yarmouth and Waveney

100

County Durham 97

Medway 85

PCT average 43

Stoke on Trent (lowest rate)

6 Source: Commons library/ONS, HSJ July 2008

Variation in prescribing

OECD (2009)

Variation in investigations

Source: OECD Health Data 2011

Variation in procedure rate

Patient Flow

• Eradicating process delays in the patient journey Length of stay reduction

• Dr Foster Hospital of the Year 2012 (assessed against 13 measures of clinical effectiveness)

Utilisation of Diagnostics

• Review and optimise ordering behaviour across the hospital

• Estimated ~25% too many diagnostic investigations

• By devolving budgets and cross charging, the incentive is with the clinical unit.

Drugs• Improving medicines management• Ensuring appropriate prescribing and

reducing undesirable variation in prescribing

• Antibiotic stewardship

Procurement and Supply

• Gaining efficiencies in procurement and supply chain processes

• Strengthening procurement team• Assessment of contracts and

contract processes• Investigate all aspects of supply

(clinical and non-clinical)

What traits does a leader require for challenging times?•Know thyself•Focus on influencing others (particularly clinicians)•Organisation culture – clinical engagement•Know how to maximise use of information to inform change•Manage change

Leadership In Challenging Times

Temple of Apollo at Delphi

“gnothi sauton”

know yourself …

Ancient Greek inscription at the Temple of Apollo, according to the Greek writer Pausanias (10.24.1)

“γνωθι σεαυτόν” or

Influencing Others

• Communication skills– Verbal, including speeches and

presentations– Non-verbal

• Interpersonal skills• Influencing skills• Negotiating skills• Emotional Intelligence

Focus on Culture

Values, Behaviours, “the way we do it here…”

• Electronic• Easily accessible• Intuitive • Real-time• Reliable and accurate• Detailed to patient and consultant

level• Available to all disciplines• Used to inform decision-making,

manage performance and DRIVE CHANGE

Information is fundamental

Benchmarked performance data

• Dr Foster Intelligence

• Shelford Group• Visits to ‘centres of

excellence’ (eg. Southampton bus trip)

The Dr Foster Unit at Imperial College, London

• Trust/partnership• Information systems• Training and education in

management

Clinical Engagement

Clinical Engagement

• Broadly accepted that developing clinical leadership is essential to the delivery of good clinical services and healthcare reform

• Variable nature and range of clinicians involved in leadership roles

• Include Nurses and Allied Health Professionals engaged in clinical work

Leadership…“It is not the critic who counts;

Not the man who points out how the strong man stumbled, or where the doer of deeds could have done better. 

The credit belongs to those who are actually in the arena, who strive valiantly, who know the great enthusiasms, the great devotions, and spend themselves in a worthy cause;

Who, at the best, know the triumph of high achievement and who, at the worst, if they fail, fail while daring greatly So that their place shall never be with those cold and timid souls who know neither victory nor defeat ”

Theodore Roosevelt