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A Mandatory Management/Leadership
Development Framework for Doctors
Professor Peter SpurgeonDirector of Institute of Clinical
LeadershipUniversity of Warwick
Enhancing Engagement in Medical Leadership
• Joint Project undertaken by National Institute for Innovation and
Improvement, and Academy of Medical Royal Colleges
• Overall goal ‘create a culture of greater medical engagement in
management and leadership with all doctors at every level’
• Two key products• Medical Leadership Competency Framework
• Medical Engagement Scale
Project Benefits
Benefits to the NHS and medical professionals include: Greater commitment and capability to effect service change and
improvement Support the drive towards the new medical professionalism Greater awareness by medical professionals of the contribution of
effective management and leadership in both operational and strategic activities
Increase and strengthen the pool of medical managers and leaders available to take on senior roles within the service
Project Products and Research
International study on preparation of doctors for leadership roles Research into the link between medical engagement and
organisational performance including Literature review Interviews with Chief Executives and Medical Directors Development of a medical engagement scale Engaging doctors publication
Medical Leadership Competency Framework
Medical Leadership Competency Framework
Describes the leadership competences doctors need to become more actively involved in the planning, delivery and transformation of health services.
The MLCF is being used to: Inform the design of training curricula and development programmes
at undergraduate and postgraduate stages of a doctors training Highlight individual strengths and development areas through self
assessment and structured feedback from colleagues Assist with personal development planning and career progression
through to revalidation The MLCF applies to all medical students and doctors
www.institute.nhs.uk/mlcf
Medical Leadership Competency Framework
Medical Leadership Competency Framework
Development of the Medical Leadership Competency Framework (MLCF) was informed by: A review of literature and key publications Comparative analysis of leadership competency frameworks Analysis of medical curricula Consultation with members of the medical and wider NHS community including
General Medical Council (GMC) Postgraduate Medical Education Training Board (PMETB) NHS Confederation NHS Employers Conference of Postgraduate Medical Education Deans (COPMeD) Medical Schools Council (MSC) British Medical Association (BMA)
Input from the project steering group, reference and focus groups, test sites and AoMRC patient/lay group.
Medical Leadership Competency Framework
Application of the MLCF will differ according to the career stage of the doctor and the type of role they fulfill. The following graphics demonstrate the emphasis that is likely to be given to the domains at each stage:
Undergraduate Continuing PracticePostgraduate
Demonstrating Personal Qualities
Doctors showing effective leadership need to draw upon their values, strengths and abilities to deliver high standards of care.
Developing self awareness: being aware of their own values, principles and assumptions and by being able to learn from experiences
Managing yourself: organising and managing themselves while taking account of the needs and priorities of others
Continuing personal development: learning through participating in continuing professional development and from experience and feedback
Acting with integrity: behaving in an open, honest and ethical manner.
Working with Others
Doctors show leadership by working with others in teams and networks to deliver and improve services.
Developing networks: working in partnership with patients, carers, service users and their representatives, and colleagues within and across systems to deliver and improve services
Building and maintaining relationships: listening, supporting others, gaining trust and showing understanding
Encouraging contribution: creating an environment where others have the opportunity to contribute
Working within teams: to deliver and improve services.
Managing Services
Doctors showing effective leadership are focused on the success of the organisation(s) in which they work.
Planning: actively contributing to plans to achieve service goals
Managing resources: knowing what resources are available and using their influence to ensure that resources are used efficiently and safely, and reflect the diversity of needs
Managing people: providing direction, reviewing performance, motivating others and promoting equality and diversity
Managing performance: holding themselves and others accountable for service outcomes
Doctors showing effective leadership make a real difference to people’s health by delivering high quality services and by developing improvements to service.Ensuring patient safety: assessing and managing the risk to patients associated with service developments, balancing economic considerations with the need for patient safetyCritically evaluating: being able to think analytically, conceptually and to identify where services can be improved, working individually or as part of a teamEncouraging improvement and innovation: creating a climate of continuous service improvementFacilitating transformation: actively contributing to change processes that lead to improving healthcare
Improving Services
Doctors showing effective leadership contribute to the strategy and aspirations of the organisation and act in a manner consistent with its values.
Identifying the contexts for change: being aware of the range of factors to be taken into account
Applying knowledge and evidence: gathering information to produce an evidence-based challenge to systems and processes in order to identify opportunities for service improvements
Making decisions: using their values, and the evidence, to make good decisions
Evaluating Impact: measuring and evaluating outcomes, taking corrective action where necessary and by being held to account for their decisions
Setting Direction
Undergraduate
• The revised Tomorrow’s Doctors released Sep 2009 includes MLCF
• Project support will include– Update to Medical Schools Council and offer support to Medical
Schools to implement MLCF– Meet with Medical School Deans to assess progress and offer advice
regarding implementation– Development of a resource and learning pack with a consortium of
medical schools– Identify minimum levels of attainment across the domains to assist in
development of appropriate assessment– Contribute to Medical Professionalism Roadshows across the UK (with
Royal College of Physicians, King’s Fund and GMC)
Postgraduate
• All Medical Royal Colleges and Faculties are undergoing a review of their curricula, PMETB has advised that the MLC is to be included in this revision.
• Project support includes:– Medical Leadership Curriculum has been developed, based on the
MLCF and provided to all colleges and faculties– Meeting with each college to discuss approach to implementation, and
how we can support this process– Providing assistance to colleges and faculties regarding assessment– Development of e-Learning for Healthcare (DH) material that will be
available to all doctors in training, regardless of specialty, in early 2010– Supporting the delivery of the new curricula with tools and support for
training clinical tutors
Continuing Practice
• Revalidation will be introduced from 2011 and the project team are working with the relevant regulatory bodies to ensure the MLCF is included in the guidelines
• Project support includes:– Meeting with SHA Medical Directors and Home Country Chief Medical
Officers to raise awareness and advise on implementation including delivery
– Contribute to review of Good Medical Practice– Work with DH, NHS, GMC and AoMRC on revalidation, providing input
on MLCF
Engagement is Critical to Organisational Performance
• Since 1997, Gallup’s extensive Q12 survey has assessed more than 4 million individuals – results revealed that of less than a third of employees (29%) are actively engaged in contributing to their employing organisations success
• In 2003 “The Quest for Quality in the NHS” (Leatherman and Sunderland) described UK clinicians as being attentive but not fully engaged in the NHS quality improvement agenda
• Successful medical engagement is crucial to future improvements in the NHS and is a policy priority with high performing NHS Trusts consistently identifying high levels of medical engagement as the key factor in achieving service improvements (Emphasised in Lord Darzi’s High Quality Care for All: NHS Next Stage Review Final Report – 2008)
• NHS organisations not only need reliable and valid tools to measure how well they engage doctors, they also need to promote and embrace a cultural change where managers and medical staff actively want to build better, more co-operative and productive relationships that drive service improvements
The Three Aims of the Research
• To develop a reliable and valid measure of medical engagement in leadership which will be quick and relatively unobtrusive to complete
• To differentiate within the scale a measure of personal engagement at an individual level (the motivation of the individual to perform in appropriate managerial and leadership roles) from the organisational context (which may foster or constrain engagement)
• To develop a systematic framework for recommending organisational strategies capable of enhancing medical engagement and performance at work
Key Assumptions of Current Approach
• Improvement in healthcare needs the positive involvement and engagement of doctors who are highly influential in planning and delivering service change
• Competence can be thought of as what someone “can do” but engagement requires a “will do” attitude
• Reliable and valid measurement and monitoring of medical engagement is critical since this will inform and shape the effective management of change
• Many definitions of engagement focus solely on individual aspect of engagement whereas the current approach also incorporates organisational conditions
• Our definition of Medical Engagement is:-
‘The active and positive contribution of doctors within their normal working roles to maintaining and enhancing the performance of the organisation which itself recognises this commitment in supporting and encouraging high quality care.’ [Spurgeon, Barwell & Mazelan, 2008]
Origins of the Medical Engagement Scale (MES)
• Applied Research Ltd. – Established large database re: attitudinal, individual & cultural aspects of NHS
• Existing measure of work satisfaction and personal commitment based on 23,782 NHS staff and 20+ health organisations
• Best items from previously established scales selected as relevant to medical engagement and re-analysed using Factor Analysis
• Scales adapted to focus on engagement - reliable, valid & relatively easy to administer & complete
Pilot Phase Focus
• Piloting took place in 4 NHS Trusts. 200-250 measures distributed, 118 medical staff returns & 19 senior managers (above 50% response rate)
• The pilot was aimed at developing a reliable and valid measure of medical engagement in leadership which will be quick and relatively unobtrusive to complete
• The measure comprised a set of items representing various scales and a behavioural checklist, enabling an assessment of the alignment between the medical and managerial perspectives
• To explore within the scale a measure of personal engagement at an individual level (the motivation of the individual to contribute to appropriate managerial and leadership roles) from the organisational context (which may foster or constrain engagement)
Scales and Definitions
Scale Definition
[The scale is concerned with the extent to which…..]
Index: Medical Engagement ...doctors adopt a broad organisational perspective with respect to their clinical responsibilities and accountability
Meta Scale 1: Working in an Open Culture ...doctors have opportunities to authentically discuss issues and problems at work with all staff groups in an open and honest way
Meta Scale 2: Having Purpose and Direction ...Medical Staff share a sense of common purpose and agreed direction with others at work particularly with respect to planning, designing and delivering services
Meta Scale 3: Feeling Valued and Empowered ...doctors feel that their contribution is properly appreciated and valued by the organisation and not taken for granted
Sub Scale 1: [O] Climate for Positive Learning ...the working climate for doctors is supportive and in which problems are solved by sharing ideas and joint learning
Sub Scale 2: [I] Good Interpersonal Relationships ...all staff are friendly towards doctors and are sympathetic to their workload and work priorities.
Sub Scale 3: [O] Appraisal and Rewards Effectively Aligned ...doctors consider that their work is aligned to the wider organisational goals and mission
Sub Scale 4: [I] Participation in Decision-Making and Change ...doctors consider that they are able to make a positive impact through decision-making about future developments
Sub Scale 5: [O] Development Orientation ...doctors feel that they are encouraged to develop their skills and progress their career
Sub Scale 6: [I] Work Satisfaction ...doctors feel satisfied with their working conditions and feel a real sense of attachment and reward from belonging to the organisation
MES Scale
MES Reliability & Validity
• Overall items reduced to 18 [or 30 for full sub-scale version] with reliability scores (Cronbach’s alpha) ranging from 0.70 to 0.93
• Inter-scale correlations with key core concepts of engagement suggest -
a) engagement is a conceptually distinct constructb) the sub-scales are important as engagement is multidimensional
• Scores from the pilot trust sites were statistically significant & in the predicted order i.e. top two are rated excellent & have taken steps to promote medical engagement, the last is in the poorest performing category & opportunistic site in the middle
MES Medical Engagement Model
FEW"Organisational Opportunities"
MANY"Organisational Opportunities"
EXPANDED"Individual Capacities"
RESTRICTED"Individual Capacities"
Doctors feelENGAGED
Doctors feelFRUSTRATED
Doctors feelPOWERLESS
Doctors feelCHALLENGED
The MES model emphasises the interaction between the individual doctor and the organisation.
The MES model emphasises the interaction between the individual doctor and the organisation.
The MES Scale Hierarchy
Climate for Positive Learning
Good Interpersonal Relationships
Appraisal & Rewards
Effectively Aligned
Participation in DM & Change
Development Orientation
Work Satisfaction
Working in an Open & Fair
Culture
Having Purpose & Direction
Being Valued & Empowered
Medical Engagement
O
I
MES Index: Position on Model for 4 Pilot Trusts
Trust C
Trust A Trust B
Trust D
Many Organisational Opportunities
Few Organisational Opportunities
Restricted Individual Capacities
Expanded Individual Capacities
Doctors feelENGAGED
Doctors feelCHALLENGED
Doctors feelFRUSTRATED
Doctors feelPOWERLESS
Meta-Scales: Position on Model for 4 Pilot Trusts
Trust A
Trust C
Trust B
Trust D
Many Organisational Opportunities
Few Organisational Opportunities
Restricted Individual Capacities
Doctors feelCHALLENGED
Doctors feelENGAGED
Doctors feelPOWERLESS
Doctors feelFRUSTRATED
Trust C
Trust A
Trust B
Trust D
Many Organisational Opportunities
Few Organisational Opportunities
Doctors feelCHALLENGED
Doctors feelENGAGED
Doctors feelPOWERLESS
Doctors feelFRUSTRATED
Trust C
Trust A
Trust B
Trust D
Many Organisational Opportunities
Few Organisational Opportunities
Expanded Individual Capacities
Doctors feelCHALLENGED
Doctors feelENGAGED
Doctors feelPOWERLESS
Doctors feelFRUSTRATED
The Levels of Medical Engagement
Embedded
Expanded
Energised
Expectant
Excluded
Doctors are fully involved at all levels in leading the design and delivery of service innovations
Doctors traditional roles have become expanded to embrace some aspects of managing healthcare
Doctors are keen to become more involved in the planning, design and delivery of services
Doctors understand the importance of becoming involved in the management agenda
Doctors are not part of the management process and confine their activities to their traditional roles
Engagement Intervention Strategies
The IHI Framework for Engaging Physicians in Quality and Safety – Reinertsen et al (2007) - comprises six areas which can be used as a checklist for engaging physicians in quality and safety.
In a similar way the hierarchical structure of the MES has also been linked to suggested potential intervention strategies and these are outlined in the hierarchical figure shown.
1.2.2
Promoting Positive
Participation
1.2.1
Promoting Individual and Organisational
Alignment
1.3.1
Promoting Leadership
Development
1.1.2
Promoting InterpersonalEffectiveness
1.1.1
Promoting an OpenLearningClimate
1.3.2
Promoting Job
Satisfaction
1.1
Promoting an Authentic, TrustingCulture
1.2
Promoting Common
Purpose and Direction
1.3
Promoting Motivation and Empowerment
1
Promoting Broad System Engagement
LEVEL ONE -FUNDAMENTAL INITIATIVE
LEVEL TWO -FOCUSEDINITIATIVE
LEVEL THREE -FIXEDINITIATIVE
PROMOTING MEDICAL
ENGAGEMENT
LEVEL AND TYPES OF INTERVENTION INITIATIVES
A LEVEL ONE change strategy tends to be FUNDAMENTAL since efforts to improve professional engagement at this top strategic level usually have the potential to impact upon any of the lower levels of the intervention hierarchy.
A LEVEL TWO initiative is described as FOCUSED since efforts to promote professional engagement at this level may still be broad in aim but are typically designed to enhance one of the three domains of engagement (i.e. engagement as relationship, involvement or motivation).
A LEVEL THREE intervention is described as FIXED because it is specifically aimed at one of the six distinct factors that have been shown to underpin professional engagement.
Levels of Medical Engagement Summary for Trust 1
Climate for Positive Learning
Good Interpersonal Relationships
Appraisal & Rewards
Effectively Aligned Participation
in DM & Change
Development Orientation
Commitment & Work
Satisfaction
Working in an Open &
Fair Culture
Having Purpose & Direction
Being Valued & Empowered
Professional Engagement
O
I
HIGH
HIGH
HIGH
LOW
MEDIUM
HIGH
HIGH
HIGH
HIGH
HIGH
Medical Engagement Scales:
Relative Normative Feedback Trust 1
KEY
High Relative Engagement (Top 1/3rd Trusts)
Medium Relative Engagement (Middle 1/3rd Trusts)
Low Relative Engagement (Bottom 1/3rd Trusts)
Levels of Medical Engagement Summary for Trust 28
Climate for Positive Learning
Good Interpersonal Relationships
Appraisal & Rewards
Effectively Aligned Participation
in DM & Change
Development Orientation
Commitment & Work
Satisfaction
Working in an Open &
Fair Culture
Having Purpose & Direction
Being Valued & Empowered
Professional Engagement
O
I
LOW
LOW
LOW
HIGH
HIGH
HIGH
MEDIUM
MEDIUM
MEDIUM
MEDIUM
Medical Engagement Scales:
Relative Normative Feedback Trust 28
KEY
High Relative Engagement (Top 1/3rd Trusts)
Medium Relative Engagement (Middle 1/3rd Trusts)
Low Relative Engagement (Bottom 1/3rd Trusts)
Levels of Medical Engagement for All Trusts in Current Sample
Engagement Meta Scale 1 Meta Scale 2 Meta Scale 3 Sub Scale 1 Sub Scale 2 Sub Scale 3 Sub Scale 4 Sub Scale 5 Sub Scale 6
Trust 1 6 10 4 7 4 23 7 3 11 7
Trust 2 15 24 13 11 23 21 20 8 12 10
Trust 3 26 23 26 26 20 22 26 23 26 25
Trust 4 22 20 22 14 22 14 23 12 16 13
Trust 5 4 4 5 4 6 5 5 6 5 4
Trust 6 11 5 17 19 7 4 14 21 13 19
Trust 7 12 9 18 15 13 6 13 25 9 23
Trust 8 27 26 28 28 26 26 29 26.5 28 28
Trust 9 19 22 10 23 15 27 10 10 27 17
Trust 10 7 6 6 10 5 12 15 1 22 6
Trust 11 10 11 9 13 8 15 8 11 19 9
Trust 12 2 2 3 1 2 1 3 5 1 2
Trust 13 14 15 16 12 19 10 11 26.5 8 18
Trust 14 9 7 8 8 10 9 6 13 6 12
Trust 15 3 3 2 3 3 8 2 4 4 3
Trust 16 8 8 11 6 9 11 16 7 10 5
Trust 17 20.5 14 23 17 11 20 22 20 17 16
Trust 18 29 29 29 29 29 25 28 29 29 27
Trust 19 18 17 20 16 18 13 25 9 21 11
Trust 20 30 30 30 30 30 30 30 28 30 30
Trust 21 1 1 1 2 1 2 1 2 3 1
Trust 22 23 25 19 20 25 24 18 19 14 21
Trust 23 24 21 25 24 22 16 24 24 24 22
Trust 24 5 12 7 5 12 7 4 17 2 8
Trust 25 20.5 16 15 21 16 17 19 16 23 20
Trust 26 28 28 27 27 28 28 27 22 25 29
Trust 27 16 13 14 22 14 18 12 15 18 24
Trust 28 17 18 24 9 27 3 17 30 7 14
Trust 29 25 27 21 25 24 29 21 18 15 26
Trust 30 13 19 12 18 17 19 9 14 20 15
Contact Details
Professor Peter Spurgeon
Professor of Health Services Management
Website: www.institute.nhs.uk/medicalleadership
Email: [email protected]
© Copyright 2008 NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges