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

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?

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

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

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

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

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

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

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

“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.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

c.j.ham@bham.ac.uk