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![Page 1: Improving the Performance of Health Services: the role of clinical leadership Chris Ham University of Birmingham 4 May 2007.](https://reader036.fdocuments.us/reader036/viewer/2022062517/56649e925503460f94b9881a/html5/thumbnails/1.jpg)
Improving the Performance Improving the Performance of Health Services: the role of Health Services: the role
of clinical leadershipof clinical leadership
Chris Ham
University of Birmingham
4 May 2007
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The puzzle for policy The puzzle for policy makers and researchersmakers and researchers
The retreat from managed care in the US
The abolition of the internal market in the UK
The return to planning in New Zealand
Why have big bang reforms not really worked?
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There is no single reasonThere is no single reason
Governments change and therefore policies change
Reforms are terminated too quickly
Politicians are impatient (and work to short term timescales)
Policies are not always well designed
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A major reason lies in the A major reason lies in the nature of health care nature of health care
organisationsorganisationsHospitals and primary care organisations
are ‘professional bureaucracies’
They are part of a ‘disconnected hierarchy’
They are ‘organised anarchies’
They cannot easily be commanded and controlled
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Health care organisations Health care organisations have inverted power have inverted power
structuresstructuresControl rests more at the bottom than
the top
Doctors and other clinicians focus on the patient
They identify with their team and department
Loyalty to the organisation is less important
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Other organisations are Other organisations are also professional also professional
bureaucraciesbureaucraciesUniversities and schools
Firms of lawyers, architects, engineers and accountants
Management consultancies
They face the same challenge
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But health care But health care organisations have some organisations have some
defining featuresdefining featuresDoctors are the most powerful of all
professions
Health care has many professions or ‘tribes’
Health care organisations are often large and complex systems
The doctor-patient relationship is the most intimate
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Health care reform led from Health care reform led from the top has to understand the top has to understand
these featuresthese features
Two examples from the UK
Re-engineering of the Leicester Royal Infirmary – led by the hospital chief executive
Giving patients booked hospital appointments – led by the Blair government
The drive from the top confronts the reality of clinical work
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Re-engineering at Re-engineering at Leicester Royal Infirmary Leicester Royal Infirmary
in the 1990sin the 1990sApplying private sector techniques to a
public service
Introduced from the top of the organisation
Limited impact and some resistance from clinical staff
Re-engineering had to be adapted in the process of implementation
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“Significant change in clinical domains cannot be achieved without the co-operation and support of clinicians . . . clinical support is associated with process redesign that resonates with clinical agendas related to patient care, services development and professional development . . . To a large degree interesting doctors in re-engineering involves persuasion that is often informal, one consultant at a time, and interactive over time . . . clinical commitment to change, ownership of change and support for change constantly need to be checked, reinforced and worked upon.”
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Giving patients booked Giving patients booked hospital appointments hospital appointments
There was wide variation between hospitals in outcomes
There was wide variation within hospitals in outcomes
Clinical ‘microsystems’ are where change happens (or does not)
24 hospitals participated in an experimental programme
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Quality improved where Quality improved where change began with change began with
enthusiastic cliniciansenthusiastic clinicians
Medical leaders were important in implementing change
Involvement by hospital chief executives was essential
Dedicated project management assisted improvement
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Clinicians resented and Clinicians resented and resisted change imposed resisted change imposed
from abovefrom above ‘You tell Tony Blair that he can give me his diary and he can see how he likes to have someone fill it for him’
Showing that patients will benefit from change is necessary but not sufficient
Doctors need to see that their work will improve too
For example, by reducing cancelled appointments and filling surgical lists
Change – even small change – is difficult
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Mintzberg’s observation Mintzberg’s observation from 20 years agofrom 20 years ago
‘government technostructures intent on bringing the professionals under their control’
have limited impact – and may be counter productive
Other ways have to be found of bringing about change in professional work
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The example of Kaiser The example of Kaiser PermanentePermanente
A self- managing medical guild
Doctors as shareholders
An exclusive relationship with the Kaiser Health Plan
Change and improvement occur from within
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Doctors are in leadership Doctors are in leadership roles throughout the roles throughout the
organisationorganisationCollegial and peer processes are used
to achieve change
Improvement occurs ‘through commitment and not compliance’
When change is agreed, it usually happens quickly
Doctors review the performance of their peers
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Not all health care Not all health care organisations are Kaiser organisations are Kaiser
PermanentePermanente
Hospitals and primary care organisations can be slow to change
The paradox of clinical innovators and conservatives
The need for an external stimulus or shock to produce improvement
A major role for national and local leaders – politicians and managers
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A story from the UK of one A story from the UK of one chief executivechief executive
He transformed one large provincial hospital over 10 years
His focus was on the development of clinical leaders and managers
At all levels in the organisation
It moved from close to the bottom into the top 10% of performers
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He then moved to a He then moved to a famous London teaching famous London teaching
hospitalhospitalThis hospital thought it was already
above the top 10%
In reality it was well behind
An organised anarchy
Doctors had limited commitment to the organisation
Their focus was on research and private practice
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Six years later it is Six years later it is improving rapidlyimproving rapidly
This hospital achieved the highest rating in the government’s ranking of hospitals
The change has occurred because of two main factors
A new chief executive
A programme to develop clinical leadership throughout the hospital
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Research from Canada Research from Canada into hospital leadershipinto hospital leadership
The importance of ‘collective’ leadership
The need for leaders to develop followers
‘Followership’ in health care is even rarer than good leadership
Relations between leaders and followers are often fragile
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What are the What are the implications?implications?
We must stop thinking about health care organisations as machine bureaucracies
We must remember they are inverted organisations
They are organisations in which the most powerful people identify with the microsystem
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In professional In professional bureaucracies, we need bureaucracies, we need
many leadersmany leadersSome will be managers, others will
be clinicians
Improving quality must be led by clinical leaders
With the stimulus and support of managers and others
A clinician-manager partnership is the way forward
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We need to invest in the We need to invest in the development of clinical development of clinical
leadersleadersTraining, development and support
at all stages
Career structures to facilitate
Payment and rewards
We need to invest in the development of followers
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Thank youThank you
C Ham Improving the performance of health services: the role of clinical leadership, The Lancet March 25 2003 online publication
C Ham et al Redesigning work processes in health care: lessons from the National Health Service, The Milbank Quarterly, 81(3), 2003