The Importance of Physician Leadership and Engagement in Quality Improvement

– Current UK Thinking – Current UK Thinking

Oliver Warren MD MRCS Surgical Registrar, North West LondonMember, NHS National Leadership CouncilClinical Lead, Prepare to Lead Scheme, NHS LondonHonorary Fellow, Department of Surgery and Cancer, Imperial College London

The UK context; Why are we

Part One

The UK context; Why are we interested in clinical leadership?

The UK NHS Context

• 1997 – 2008 saw significant expansion in funding, increasing the quantity of care

• 1996/7, NHS budget in England was £33 billion; in 2008/9 it was £96 billionin 2008/9 it was £96 billion

• Significant spend on staff – increase in both numbers and salaries

• Improved performance as measured in process measures – Four hour wait in ED– Two – week suspected cancer wait

The Next Stage Review• 2008 onwards – shifted the

emphasis to quality• Based on clinically led,

local visions, developed by Strategic Health Authorities

• Put quality at the heart of the NHS by making it the ‘organising principle’

• Identified clinical leadership and engagement as essential to achieving this aim

NHS 2010–2015: from good to great

• Last 18 months economic challenges have focused NHS on a new ‘landscape’ ‘QIPP’, quality, innovation, productivity and prevention

• Aims remain the same but • Aims remain the same but with key driver for change being economic pressure

• With 80% of expenditure occurring as a result of clinical decisions, clinical leadership remains integral to the quality agenda

Touchstones in our Culture• ‘There was a lack of leadership,

and of teamwork’• ‘Those in positions of clinical

leadership must bear the responsibility for this failure’

• ‘The highest priority still needs to be • ‘The highest priority still needs to be given to improving the leadership and management of the NHS at every level’

• ‘Fundamentally …led back to one principal flaw: a lack of effective leadership’

• ‘There was power, but no leadership’

Touchstones in our Culture• ‘The nurses had not had enough

training and development, and leadership had been weak’

• ‘[The Board] failed to pay sufficient regard to clinical leadership’

• ‘[The remaining ED consultant] • ‘[The remaining ED consultant] ..was described by many of his medical and nursing colleagues as a poor leader’

• ‘There was a longstanding lack of medical and general leadership’

• ‘there was a lack of nursing leadership’

• ‘lack of leadership left junior doctors demoralised’

Touchstones in our Culture• ‘concern about a lack of focus,

leadership, follow through and management’

• ‘the management and leadership of wards needed to improve’

• ‘Clinical leaders failed to attend the • ‘Clinical leaders failed to attend the governance and risk committee, which provided little leadership to the directorates’

• ‘The leadership was seen by staff as giving priority to finance and access targets which had an effect on the control of infection’

Academic Justification

Academic Justification

Academic Justification

Average operational

Least clinically-led

Most clinically-led

Scores derived from interviews with 170 NHS hospitals (1= low; 5=high)

3.13.02.72.2

Source: McKinsey/LSE survey “Management Matters” (McKinsey Quarterly and HSJ, 2008)

operational effectiveness score

Average performance management score

1st 2nd 3rd 4th

Quartile

2.82.62.22.1

Developing physician leadership

Part Two

Developing physician leadership and engagement in Quality – the

barriers

Do physician leaders currently have the skills to address this challenge?

8 fold variation in rate of use of among Emergency Department attendings. Physician 1 uses 40% more

head CT scans than next highest practitioner

Source: Thomas H. Lee, MDNetwork President, Partners Healthcare System

• Limited knowledge and understanding of current concepts and methods of quality improvements • Working and leading across professional boundaries

Knowledge &Skills

• Differing definitions about what constitutes high quality care• ‘Being a professional’ guarantees high quality care –resistance towards any move away from self-regulation

Challengesbelief

systems

• High quality care is already being provided ‘at least by us’• Reliance on dubious indicators of quality e.g. lack of Denia l

Why don’t Doctors lead and engage in quality improvement?

• Data is ‘not accurate’, ‘scientifically robust’ or ‘valid’• Data is qualitative, methodologies and sources are unfamiliar• Patient engagement and co-production highly foreign

• Reliance on dubious indicators of quality e.g. lack of complaints

Denia l

• Potentially deleterious impacts arising from performance measurement e.g. blame• Professional authority challenged, loss of autonomy & status

• Quality initiatives at best will be ineffective and at worse may waste scarce resources. • ‘We don’t have enough money to ‘do’ quality’

Resources

Risks & Concerns

Data

The Underlying Barriers to Clinical Leadership

UK efforts to re-define the role of

Part Three

UK efforts to re-define the role of the clinician

The NSR - the triple role of the clinician

• Practitioner – delivering care• Partner – taking responsibility for appropriate

stewardship and management of finite healthcare resourceshealthcare resources

• Leader – offering leadership, and where they have appropriate skills, take senior leadership & management posts in research, education and service delivery

Redefining the role

Enhancing Engagement in Medical Leadership

Example; Demonstrating Personal Qualities

UK initiatives to develop physician

Part Four

UK initiatives to develop physician leadership and engagement in

Quality

Creation of the National Leadership Council

NATIONAL LEADERSHIP COUNCIL

The Next Stage Review High Quality Care for

“We will establish an NHS Leadership Council which will be a system wide body chaired by the NHS Chief Executive, responsible for overseeing all matters of leadership across healthcare, including the top 250 leaders.

It will have a particular focus on standards (including Quality Care for all stated:

It will have a particular focus on standards (including overseeing the new certification, the development of curricula, and assurance) and with a dedicated budget, will be able to commission development programmes.

”

NLC Vision;

‘ An NHS with outstanding leadership and leadership

NATIONAL LEADERSHIPCOUNCIL ACTIVITIES

Ensure the delivery of the NSR leadership commitmen ts set out in High Quality Care for All1

Set out clear priorities for culture change and leadership across the NHS2

Produce an annual report for NHS staff featuring examples of inspiring leadership and best practice, progress towards the priorities and future challenges

3leadership development at every level to ensure high quality care for all’

Ensure standards for leadership and leadership development including methods of accreditation4

Oversee the effectiveness of national funding and commission programmes and activity where appropriate5

Make recommendations for policy to influence the valuing of leadership and the employment environment for leaders across the service.6

Exchange knowledge with other sectors, forge partnerships to foster innovation, find and share best practice and celebrate success.7

NLC OPERATING MODEL

National Leadership Council

Chaired by HS Chief Executive

The NLC is Chaired by David Nicholson, NHS Chief Executive. The NLC is a sub-committee, accountable to the NHS Management Board. It has 26 Core Members who are recognised as excellent leaders. It also has 12 Fellows and 5 Patrons.

NLC Structure

NLC PRIORITIES

Clinical Leadership

EmergingLeaders

Top Leaders

Board Development Inclusion

Mark Goldman

Elisabeth Buggins

Barbara Hakin

Prem Singh

SueJames

Undergraduate & Postgraduate Curricula

Leadership

Governance Programmes

Enhance the professionalism

Increasing capacity and capability

Create a

Clinicians

BME

Women

Breaking Through

GatewayLeadership for Quality Certificate

Clinical LeadershipFellowships

professionalism and quality of NHS boards

Equip them to meet economic challenges and longer-term objectives

Create a supply of NHS talent to take on the most challenging roles

Develop senior leaders

Women

External Talent

Management Training Schemes

Use of social and physical networks

Leadership Model: Vision, Method & Behaviours: Lead – Clare Chapman

Talent and Leadership Planning: Lead – Clare Chapman

Manager Regulation including Masters Programmes: Lead: Ian Dalton

Key purposes

Nat

iona

l

Reg

iona

l

• National Leadership Council – Annual Report• Commission leadership development for undergraduate and

postgraduate curricula and NHS top leaders• Evidence gathering on capability and capacity

• Regional talent and leadership plan • Commission development programmes

(e.g. for aspiring Chief Executives, Executive Directors, Senior Clinical Leaders, Emerging Talent)

OVERVIEW OF THE TALENT & LEADERSHIP FRAMEWORK

Key Principles at every purposes R

egio

nal

Em

ploy

er

Indi

vidu

alLeadershipfor quality

Subsidiarity

• Organisation diagnostic and improvement plans

• Provision of assurance where funding has been made available

• Commission and implement programmes (e.g. Trust Board Development, Leadership for Quality)

• Personal development plan and career portfolio

• Coaching, teaching and/or mentoring others

at every level

Clinical Leadership• Quality assurance

– Define core curriculum requirements, accredit leadership programmes and award certification levels

• Supporting current programmes– NLC Leadership Fellows – requires dispersion and elaboration

into a national programme– Regional Clinical Leadership Fellows or ‘Darzi Fellows’– Regional Clinical Leadership Fellows or ‘Darzi Fellows’– Academic credibility –chairs in Clinical Leadership to be created,

attached to current Schools of Medicine– Communication – a compelling narrative will be created and

disseminated through traditional and newer media• Removal of barriers currently in place that deter high quality clinicians

from taking on significant leadership roles • More intelligent use of the merit award system• Use of social networking and technology to create a ‘movement’ and

‘community’

Increasing Junior Doctor Engagement in Clinical Leadership

• Prepare to Lead• Clinical Leadership Fellows (‘Darzi Fellows’)

• CMO’s Clinical Advisor’s Scheme• CMO’s Clinical Advisor’s Scheme

• BAMMbino

• Patient Safety First Campaign

• Enhancing Engagement in Medical Leadership

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BAMMbino

• Founded in late 2007 as an off-shoot of the British Association of Medical Managers

• Aims to – ensure that high quality leadership and management skills are

nurtured from an early stage in doctor's careers nurtured from an early stage in doctor's careers – provide support and advice for those who wish to be the Clinical

Directors, Medical Directors, Chief Executives and Chief Medical Officers of the future

– act as a network of enthusiastic Junior Doctors who see medical management and leadership as an intrinsic part of their future careers

– act as a portal for information, advice and support

BAMMbino

150

200

250

0

50

100"BAMMbino Membership"

Clinical Leadership Fellows

• Year long posts, first announced in the Next Stage Review• First trialed as ‘Darzi Fellows’ in London, April 2009• April 2010 present in every SHA• Variations throughout regions but in most cases;

– Registrars within 2-3 years of CCT– Work on “live” change management, safety or QI programmes in their

specialty and within their organisation– Each post defined, advertised and recruited through individual trusts

and reports to individual Medical Directors– Bespoke course and learning sets with other fellows

• Quality assured by NLC, with central funding

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The Chief Medical Officer’s Clinical Advisor’s Scheme

Prepare to LeadAims

To begin developing a group of

high potential registrars as

leaders and managers for the

future, equipping them with an

understanding of the current

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understanding of the current

issues facing the NHS

To produce clinicians who can

drive health care change across

London, taking a strategic view,

contributing ideas, taking the

platform and leading change.

Selection criteria

• Potential• Commitment to;

– Healthcare for London– Improving quality of – Improving quality of

patient care

• Ambition• High levels of self-

awareness• History of delivering

high quality results

Process

Outcomes•Input to Healthcare for London workstreams such as End of Life, Maternity and Child Health Pathways•Number of participants taking on significant roles;

–Educational adviser, NICE–Technological adviser, NICE–Two clinical advisers to the CMO–Clinical adviser to Minister, DH–Chair, BAMMbino–Clinical Lead High Quality Care, NHS Hammersmith & Fulham–Two appointments to the National Leadership Council

Four key methods of development;1.The Mentoring Relationship 2.Workshops and Seminars3.Network and the Cohort Effect

Three key areas of discussion;1.Develop the few or the many?2.Uniprofessional vs. Multiprofessional vs. ‘Hybrid’

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3.Network and the Cohort Effect4.The Opportunities

vs. ‘Hybrid’3.Future utilisation of the talent and the energy

Three issues for mentees;1.‘Re-entry’ issues to clinical work2.Dealing with regressive or resistant colleagues particularly seniors3.Loss from clinical work of talented physicians

Questions for Discussion

• What can your organisations do to build more clinical leadership and engagement?

• How can you successfully bring your managers and clinical staff, particularly doctors, together in partnership?partnership?

• How will you communicate the benefits?• How will non-clinicians respond? • Is there anything this group can do?

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Thank You

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