FIMDP 2013

DEPT OF COMMUNITY MEDICINE

SRM MEDICAL COLLEGE ,SRM UNIVERSITY

&

UNSW AUSTRALIA

9TH & 10TH JAN 2013

School of Public Health and Community Medicine

Seminar on Health Care Management

9th and 10th of January, 2013

Department of Community Medicine

SRM Medical College Hospital &

Research Centre

SRM University

Principle challenges of health

management

By way of introduction

University of New South Wales

• Established in 1949

• Ranked among the top 60 universities

in the world

• Founding member of Group of Eight

and of the Universitas 21

• More than 50 000 students from over

120 countries

• Eight faculties - Arts and Social

Science, Built Environment,

Engineering, Law, Medicine, Science,

Business and Fine Arts

School of Public Health and Community

Medicine (SPHCM)

• A leader in public health, community medicine, health management and system strengthening

• An extensive alumni network in Australia, the Asia-Pacific region and beyond

Faculty and students

> 90 academic, general and research staff> 200 conjoint or adjunct staff in clinical and research units

6 associated research centres

>$32 million in research funding > 400 published peer-reviewed papers a year

> 100 enrolled PhD candidates> 500 postgraduate coursework students.

Research strengths

• Infectious diseases

• Primary health care

• Health services management and research

• Global Health

• Indigenous health

• Ageing and aged care

• Social research

SPHCM Masters level programs

• at the core of the SPHCM curriculum;

• local and international reputations for:

– their relevance to work practice; and

– strong emphasis on adult education approaches to

learning.

• career-defining qualifications

Master of Public Health (MPH)

Master of International Public Health (MIPH)

Master of Health Management (MHM)

Dual degrees:

MPH/MIPH

MPH/MHM

MIPH/MHM

Enrolments in 2012

• Public Health 219

• Health Management 155

• International Public Health 83

• MPH/MHM 108

• MIPH/MHM 38

• MIPH/MPH 40

• PhD 113

Our students

• Currently over 500 students

• 25% international - from Asia, Africa, India, the Middle

East, Pacific, Europe, North and South America

• Medical, nursing and allied health backgrounds

• Minimum entry requirements for Masters coursework

programs

– Health or health related degree

– At least 2 years’ health or health related work experience

– English level minimum of IELTS 6.5 (TOEFL 100)

o Good English writing skills are essential for success

o Support for Academic Skills available at UNSW.

Master of Health Management (MHM)

• Oldest health management program in Australia (30 years)

• Internationally recognised

• Accredited by the Australian College of Health Service Executives

• Alumni hold senior health management positions globally, particularly in Asia/Pacific

• MHM program designed to

• meet the needs of health managers (Australia and other countries)

• set the benchmark for health services management training

• MHM program equips graduates to

• be leaders in their field

• develop skills & knowledge to manage health services effectively

• produce and evaluate health policy and related research

• effectively deal with workforce and finance issues.

MHM program structure

Core courses Units of

Credit

Semester*

Foundations in Public Health and Health Care Systems 6 1

Strategy, policy and change 6 1

Healthcare economics and financial management 6 1

Health leadership 6 2

Clinical governance and risk 6 2

Evidence informed decision making 6 2

The program comprises 48 units of credit (UOC) consisting of 36 UOC of core

courses and 12 UOC of elective courses. Each course contributes 6 UOC.

Core courses Electives

Health Promotion and

Social Perspectives of

Health*~

Community

Development

Economic Evaluation in

Health Care

Principles and Practice

of Primary Health Care

Services in the

Community

Management of

Laboratory Services

Foundations In Public

Health and Health Care

Systems *+~

Advanced Health

Economics and

Financial Management

Comparative Health

Care Systems

HIV Aids: Australian and

International Responses

Managing Human

Resources for Health

Epidemiology and

Statistics For Public

Health*

Program Design and

Evaluation

Advanced Biostatistics

and Statistical

Computing

The Global HIV

Epidemic: Social

Aspects and Impacts

Outbreak Investigation

Strategy Policy and

Change+

Qualitative Research

Methods

Advanced Epidemiology Inequalities and Health Public Mental Health in

Australia

Healthcare Economics

and Financial

Management+

Prevention and

Management Of Chronic

Disease

Tobacco, Alcohol and

Illicit Drugs

Health Impact

Assessment

Current Challenges In

Infectious Disease

Health Leadership and

Workforce

Management+

Applied Research

Methods For Public

Health

Reproductive, Maternal

and Children's Health

Public Health

Perspectives of

Indigenous Health

Communicable

Diseases in

Humanitarian

Emergencies and

Disasters

Clinical Governance and

Risk Management+

Ethics and Law In

Public Health

Rehabilitation and

Restorative Care

Indigenous Health and

Wellbeing Across The

Lifespan

Tropical Disease Control

Evidence-informed

Decision-making+

Policy Studies Management of Aged

Care Programs and

Services

Case Studies in

Aboriginal and Torres

Strait Islander Health

Mathematical Modeling

of Infectious Disease

International Health~ Environmental Health Health Aspects of

Crises, Emergencies

and Disasters

Social and Cultural

Aspects of Contagion

Communication in

Public Health

*Core course in MPH

+Core course MHM

~Core course in MIPH

Managing health services:Perspectives and challenges

‘Modern’ approaches to management

• The 20th Century has been called the ‘management’

century

• Roots of current management theory in engineering and

predominantly in the USA

• Three ages of management:

• The age of scientific management (productivity) from

early 1900s until WWI

• The age of modern management (human relations

and strategic thinking) until the 1980s

• The age of change (‘nervous’ globalism, GFC and its

causes, focus on transformational leadership)

From management to health management

• What makes managing health services different to

managing other types of public and private services?

– All the same areas of practice +++++

– Health systems are complex, and prone to wicked

problems

Productivity Commission 2010, Strengthening Evidence Based Policy in the Australian Federation, Volume 1: Proceedings, Roundtable Proceedings,

Productivity Commission, Canberra. http://www.pc.gov.au/research/confproc/strengthening-evidence 18

• Planning and goal setting

• Strategy development and

implementation

• Decision making

• Innovation and change

• Human resources and diversity

• Organisational behaviour

• Leadership

• Motivation

• Communication

• Productivity and quality

• Marketing

• Finance and accounting

• Project management

• Operations management

• Occupational health and safety

• Location and resources

• Legal and regulatory requirements

• Training and development

• Work based learning

• Finance

• Teamwork

• Policy and guideline development

• Compensation and payment

• Development of adaptive ‘learning’

organisations

• Recruitment and retention

• Job analysis

• Career development

• Performance management

• Employee well being

• Work life balance

• Organisational communication

• Corporate culture, climate and

environment

• Information technology

What does management involve?

• Health insurance

• Public and private financing

• Health system organization

• Overall health care spending

• Hospital spending and utilization

• Health care access

• Chronic care management

• Disease prevention

• Capacity for quality improvement

• Public views and loss of trust

• Ethics (professional, public)

• Innovations

• Performance indicators

• Efficiency and integration of

services

• Care coordination

• Use of health information

technology

• Use of evidence-based practice

• Translational research

• Cost containment

• Accreditation, regulation

• Reforms

• Health disparities

• Quality of care

• Patient safety

In addition healthcare managers are

concerned with:

Research

Inputs

Processes

Socio-cultural, political, economic and legal context

Outputs

and

outcomes

Equity

Quality and

safety

Acceptability

Efficiency

Workforce

Finance

Governance

Consumers

population,

groups,

individuals

Public

health

Primary

healthcare

Hospitals

Specialist

services

and

providers

Pharma-

ceuticals

Aged care

and

disability

services

Research

CommunitiesEnvironments

Consumer

Numbers

Education

of health professionals

Assistive

technology

Community

health

Structural

Political

Cultural

Educational

Emotional

Physical and technological

Specific challenges in achieving and sustaining

healthcare quality

Bate, Mendel and Robert (2008)

So what makes healthcare settings different?

• The stakes are very high

• The level of stress can be intense

• The demands are multiple and ongoing

• Staff have to deal with errors and adverse events as well as

patients/families (Yu’s ‘second victim’)

• Staff’s identities are tied up with their jobs/roles

• There is a culture of commitment (good and bad)

• Staff are exposed to risks far beyond those of the general population

• High and increasing levels of media, government and public scrutiny

• It’s rarely just a ‘job’

• Multiple professions, disciplines, approaches, attitudes, experiences

• Emerging roles, professions and practices, including those of

administrative and ancillary staff

Key challenges in health

management

Is high quality, high safety healthcare possible?

• Given the chaos of current world events?

• Given the turbulence of health care systems?

• Given the types and range of illnesses, diseases and

injuries treated?

• Given the history, power and embedded structures of

professions and services?

• Given the limitations of the knowledge and practice

of quality improvement strategies and systems?

• Given the complexity of clinician-patient

interactions?

• Given … [your own personal concerns] …?

Some key challenges

1. What are the current and future issues healthcare services?

2. How do we manage change and the pressure to change?

3. How do we improve communication and teamwork?

4. How do we look at the healthcare system in a new way?

5. How can we act as both managers and leaders?

6. How can we address inequities at all levels of the health system?

7. How can we make a difference?

Challenge 1: current and future

issues affecting healthcare

Scanning the horizon

Challenge 1: Issues affecting healthcare globally

and global healthcare

1. Demography

2. Healthy behaviours

3. Disease and disability

4. Workforce

5. Public attitudes and expectations

6. Broader determinants of health

7. Medical advances

8. Information technologies

9. Sustainable services

10.Economic pressures

The King’s Fund

Challenge 2: managing change

Managing the inevitable

Change

• Continuous or intermittent/sequential or

spasmodic/sudden/disruptive

• Managed/unmanaged

• Proactive/reactive

• The act or fact of changing; substitution of one thing for

another; succession of one thing in place of another;

substitution of other conditions or circumstances, variety.

(OED)

Patient safety strategies fall into eight categories

Change the awareness level of the individual

Change the skill of the individual

Change the practice

Change the environment

Change the task

Change the team

Change the organisation

(service, hospital)

Change the system

Challenge 3: How do we manage change?

Questions [we often fail] to ask about change:

1. What is the (perceived) relative advantage of the innovation/change?

2. How compatible is the innovation to the people who are meant to implement it?

3. How complex is the innovation?

4. Can we pilot it first?

5. Will everyone be able to see the outcomes?

6. How will we know that it is successful?

Modified from Professor John Øvretveit

How do we change culture (at organisation or

team level)?

Laraine Kaminsky

Elements of culture

Raymond Williams

How does culture affect safety?

• Lack of integration of health care systems and services

• Resource shortfalls, competing priorities and inadequate

staffing and work overload

• Financial incentives to conceal errors

• Acceptance of poor, expectation of good quality services and

techniques

• e.g. written and oral communication

• Teams and services that are fragmented

• Professional and organisational culture clashes (including

definitions of errors)

• Lack of senior leadership involvement in safety strategies

Hindle, Braithwaite, Iedema (2005)

Hindle, Braithwaite, Travaglia (2006)

How does culture affect safety?

• Lack of clinician engagement

• Blame and shame, the ‘eating of young’

• The catching and or concealment or errors and near misses by

colleagues

• Treatment of whistleblowers and other system critics

• Involvement of consumers and carers

• Resistance to change

• Rate of change and innovation

• Level(s) of commitment to organisational learning and

improvement

• Integration of safety programs and the use of data

Hindle, Braithwaite, Iedema (2005)

Hindle, Braithwaite, Travaglia (2006)

What does safety culture look like?

Safety culture has been be defined as ‘… the product of

individual and group values, attitudes, perceptions,

competencies,and patterns of behavior that determine the

commitment to, and the style and proficiency of, an

organization's health and safety management.’

Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study

Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993.

Sexton JB, L Helmreich RL, Neilands TB, Rowan K, Vella K,

Boyden J, Roberts PR, Thomas EJ. (2003) The Safety Attitudes

Questionnaire: psychometric properties,benchmarking data, and

emerging research. BMC Health Services Research, 6(44),

doi:10.1186/1472-6963-6-44

• No perceived benefit to those

implementing the change and their

patients

• High levels of insecurity (based on fear

or reality)

• May diminish their current

power/authority/status/wages (status

quo)

• Fear that the change might disrupt

their social and or professional

relationships

• Self-interest

• Feel a responsibility for the quality of

care

• Desire to uphold tradition

• Different goals and perspectives to

their managers

• Lack of trust of management

• High levels of existing or generated

uncertainty

• Unclear, misleading or conflicting

communication

• Lack of understanding of the change

and its purpose

• Mismatch between new innovation and

approach and skill set of staff

• Short implementation timeframes

• No consultation

• No leadership as opposed to

management

• Change burn-out

So why do people resist change?

Health staff are concerned about …

• Systems issues, including:

– Increases in ageing and disabled population(s) with

multiple co-morbidities

– Increase in chronic and complex illnesses

– These changes in population were seen as adding to

the complexities of care and potential for error

• Organisational issues, including:

– Inadequate resource management

– Heavy workloads

– Staff shortages

– Increased demands on staff for shiftwork

– Dependence on the use of causal staff

Health staff are concerned about …

• Teamwork issues, including:

– Poor communication

– Professional culture clashes

– Poor teamwork

– Pressure from inexperienced staff

• Individual issues, including:

– Emotional anxiety about witnessing or being involved in errors

– Personal and colleagues’ accountability for errors

– Increased patient aggression

– Burnout, tiredness

– Fear of litigation

Why is this important?

Staff under stress are likely to take up positions where they:

• Strong defence of current positions and tactics;

• Resort to familiar behaviour, irrespective of whether that

behaviour contributed to the error/disaster;

• Repeat of past solutions, irrespective of their applicability

to the current situation.

(Roberts, Madsen, & Desai, 2007, Weick 1990)

41

Again, why do people resist change?

They may not be ‘resisting’ change:

• Resisting ‘bad’ managerial decisions

• Not resisting at all, but confused as to how

to process and proceed

What can healthcare managers do? …

• Health workers are motivated to perform well when their organization

and managers:

• provide a clear sense of vision and mission;

• make people feel recognized and valued whatever their job;

• listen to staff and increase their participation in decisions;

• encourage teamwork, mentoring and coaching;

• encourage innovation and appropriate independence;

• create a culture of benchmarking and comparison;

• provide career structures, and transparent and fair opportunities for

promotion;

• give feedback on, and reward, good performance – even with token benefits

• use available sanctions for poor performance that are fair and consistent.

Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health

Organization

Improving our processes and our people

Challenge 3: How do we

improve communication and

teamwork?

Challenge 4: How do we improve

communication and teamwork?

The last half century has brought a sea change in the

provision of medical care, with massively increase complexity

… huge numbers of new medications and procedures, and

overwhelming evidence that the quality of teamwork often

determines whether patients receive appropriate care

promptly and safely … the outcomes of trauma care,

obstetrical care, care of the patient with an acute myocardial

infarction or stroke, and the care of the immunocompromised

patient are likely to hinge more on the quality of teamwork

than the brilliance of the supervising physician..

Watcher (2008) Understanding patient safety. p.100

Highly

ineffectiveAverage

performanceHighly effective

Hete

rogeneous

team

s

Hom

ogenous team

s

He

tero

ge

ne

ou

s te

am

s

Interprofessional factors affecting patient safety

• Communication and teamwork (Lyndon, 2006, Chacko et al, 2007), Manser, 2009)

• Peri-operative briefings (Lingard, et al 2008)

• Handovers (Nagpal et al 2010a; Nagpal, et al 2010b, Botti, 2009, Smith, 2008)

• Interdepartmental and inter-organisational relationships (Waring

et al, 2006, Fin et al 2006)

• Patient empowerment and involvement (Walton et al 2010; Howe: 2006)

• The importance of non-technical skills in surgery (Flin, et al 2008)

• Interprofessional conflict (Baldwin, Daugherty: 2008)

• Disaster management (Attack et al2009)

Interprofessional factors affecting patient safety

• Structures

• Processes and systems

• Roles and responsibilities

• Legal requirements

• Space and place

• Decision/sense making methods and models

• Group and interpersonal dynamics

• Patient/family involvement

Braithwaite, Travaglia (2005)

Hindle, Braithwaite, Iedema (2005)

Travaglia, Nugus, Braithwaite (2006)

Travaglia, Braithwaite (2010)

Nugus, Greenfield, Travaglia, Braithwaite (2010)

• The logic of assessment

• The focus of efforts

• The locus of responsibility

• The pace of action

• The focus of attention

• Interprofessional stereotypes

• Decision making expectations

• Beliefs about professional independence

Conceptual and practice differences (Qualls and Czirr,

1988)

Visualising professional

differences

Administrative staff’s view on safety and quality

Nurses’ views on safety and quality

Doctors’ views on safety and quality

Allied Health’s views on safety and quality

Managers’ views on quality and safety

Providing a new vision for others to follow

Challenge 4: How do we look

at the healthcare system in a

new way?

Challenge 4: How do we look at the

healthcare system in a new way?

• Wellness versus illness systems

• Rocks versus birds

• Professional/patient/person/relationship centred

care?

• Who are our patients?

Paul Plsek, from Richard Dawkins; Douglas Eby

A rock or a bird?

Inanimate object or complex system

Is providing health care like

throwing …

SouthCentral Foundation Alaska

Patient centred approach to service delivery

It is more important to know what kind of a

patient has an [iatrogenic] disease than to

know what disease a patient has.

William Osler

Premise

• The patient safety movement has utilised systems theory and

risk perspectives to help identify and address the

organisational, team and clinical dynamics contributing to

errors and adverse events

• Interactions in healthcare are as influenced by the social-

cultural, and economic contexts of the patients as they are by

organisational, technical and workforce factors

• There is significant evidence on how social, situational an

structural vulnerability impacts on groups’ ability to access,

utilise and benefit from healthcare

• But less is known about how social, situational, structural and

system vulnerabilities affect the safety of healthcare

Sharing the load

Challenge 5: How can we act

as both managers and

leaders?

Challenge 5: How can we act as both managers

and leaders?Old management paradigm New management paradigm

Organisation discipline Organisation learning [lifelong]

Vicious circles Virtuous circles

Inflexible organisations Flexible organisations [Proactive]

Administrators Leaders

Distorted communication

(Information as power)

Open communication [information overload]

Hierarchies Markets [communities, networks]

Products driven by SBUs Products driven by core competencies

Apex strategic learning Widespread strategic learning

Theory x (most employees are not trustworthy) Theory y [+ + +]

(most employees are trustworthy)

Most employees are disempowered Empowerment [including patients]

Managerial prerogative must control local

knowledge of employees

Employee knowledge

(critical to success and creativity, creates on

prerogative)

Creating a healthcare system of leaders

• Beyond individual leaders - because of all the previous challenges,

healthcare systems need:

• Shared leadership versus individual leadership

• No heros – UK NHS – idea of servant and distributed leadership

• Importance of followership as well as leadership

• Increased focus on interactions and relationships

• Creation and support of networks and communities of practice

• Creation and support of learning organisations (Senge: systems

thinking, personal mastery, mental models, shared vision, team

learning)

• Focus on values (principles as the compass that point us in the

right direction) Covey

Peter Drucker

Managers do things right,

Leaders do the right thing.

Sharing the load

Challenge 6: How can we address

inequities?

Challenge 6: Dealing with inequities

How can we ensure that healthcare services are

safe, effective, patient-centred, timely, efficient and

equitable for all people

(Crossing the Quality Chasm)

• Equal access

• Equal utilization

• Equal quality of care

• Equal outcomes

Who is at risk in healthcare?

• The elderly

• Indigenous people

• People from CALD and refugees

• People with disabilities, especially cognitive impairments

• Children and youth

• Patients with literacy and communication problems

• People from lower SES

• Geographically isolated individuals

• Socially isolated individuals

• The homeless

• The frail and malnourished

• Patients with co-morbidities and chronic illness

• Patients with high acuity

Four factors every healthcare manager will deal

with ...

Complexity Diversity

Differentiation Context

Challenge 7: Can we make a

difference as managers?

Good news: good healthcare management

practice does make a difference

• Healthcare management practice (measured by operations,

performance and ‘talent’ management) was strongly related to

• Clinical outcomes (e.g. heart attack mortality rates)

• Patient satisfaction

• Hospital financial performance

• Healthcare management practices undertaken in the UK had resulted

in:

• Good UK average score vs other countries survey but

• Wide intra-country variations in practice (irrespective of

funding or physical size of country)

• No direct correlation between health expenditure and

management practices (and outcomes … the opposite in fact)

72

Good news: good healthcare management

practice does make a difference

• Five factors associated with better healthcare management practice

were:

• Share of clinically trained managers (more clinician managers,

better overall outcomes, particularly if those clinicians have

management training)

• Degree of competition (tougher competition better outcomes)

• Hospital size (larger hospitals have better outcomes)

• Managerial autonomy

• Hospital ownership (private have slightly higher scores)

Professor John Øvretveit

But they can also contribute to latent failures in

healthcare ...

Actions or inactions by managers/supervisors that cancontribute to the probability of errors:

• Heavy workloads of staff

• Poor communication between managers, clinicians and staff

• Lack of maintenance of buildings and equipment

• Lack of knowledge or experience of the manager

• Inadequate supervision of clinicians and staff

• Stressful environment

• Rapid organisational change

• Conflicting goals between managers and clinicians

So what is required of health services managers?

• Knowledge of the field; values; culture (Lawson & Rotem: 2004)

• Leadership; organisational planning; external relations; monitoring and

evaluation (Liang and Brown: 2008)

• Technical skills; industry knowledge; analytical and conceptual reasoning;

interpersonal and emotional intelligence (Robbins et al: 2001)

• Personal skills; interpersonal skills, group skills, communication skills (Carlopio

and Andrewartha: 2008)

• Leadership; communication; lifelong learning; consumer/community

responsiveness and public relations; political and health environment

awareness; conceptual skills; results oriented management; resources

management; compliance with standards, ethics and laws (CCHSE: 2005)

• Local knowledge; basic skills of working with people; basic skills of working

with data; library of theory; toolbox of technical knowledges and methods;

repertoire of different managerial personae; judgement or self knowledge,

ethical practice (Smyth et al, in Harris 2006)

• Wisdom (Rooney, Mintzberg, Reason, various)

Repertoire of Management Personae

• as teacher (high level knowledge and technical skills, role modeling, individual relationships with staff)

• as bureaucrat (guardian of roles, rules and relationships)

• as general (staff obedience, organisational flexibility and excellent intelligence about environment)

• as accountant (control of assets and expenditure)

• as engineer (production process as machine)

• as people person (relationships)

• as leader (create conditions for good decision-making and to project reassurance and confidence

(Legge & Stanton, 2002)

The final challenge

Final challenge: how can we see what we do

and who we are in a different light?

• Communication as the core of all healthcare

• The need for integration – co-ordination – collaboration

• The absolute necessity of multidisciplinary,

multiprofessional and multiperspective teams

• The balance of accountability and professional autonomy

• The role of the person in healthcare

Healthcare managers can contribute by ...

• Changing culture

• Engaging clinicians and staff

• Actively listening to and involving patients and

their families and communities

• Stop thinking rocks, start thinking birds

• Stop being the hero at the front, and start being

the leader at the heart

A little parable…

THANK YOU