School of Management

1. School of Management SEMINAR

2. Leadership and Better Patient Care: From Idea to Practice An SDO-Funded Project on Leadership within the NHS A presentation to the CPSO By Yiannis Gabriel Professor of Organizational Theory

3. Team Members • Professor Paula Nicolson (Principal Investigator) • Professor Yiannis Gabriel • Dr Kristin Heffernan • Mr Chris Howorth • Dr Paula Lökman (researcher) • Dr Dana Rosenfeld • Ms Emma Rowland (researcher)

4. Project Outline • SDO Funding (£400k) • 3 Years (2006 – 2009) • Participating hospitals • Guys/St. Thomas’s and Central • Middlesex/Northwick Park • Ashford and St Peter’s

5. Project outline • Aims • To what extent can leadership be a vehicle for organizational change in the NHS? • Does leadership affect patient care and how? • What do people who work in NHS hospitals understand as leadership? • What is good leadership/less good/bad leadership? • What does patient care mean to different stakeholders in the NHS?

6. Some features of the project • Does not start with assumptions about leadership and patient care; • Seeks to identify how participants experience leadership and patient care; • Is not top-down • Involves a variety of methods, including • Survey on organizational climate • Focus groups • Interviews • Observations

7. Stories as a feature of the research • Stories as a way of conveying experience, emotion and meaning • Stories as a form of sharing knowledge and generating learning • Stories as a means of influencing hearts and minds • Stories as a major force that sustains organizational culture

8. Two core issues • Ethical approval • “Were we to be honest with MREC they would place restrictions that would make our practive as researchers less ethical.” (Professor of Medicine and practicing GP) • Access • Need to maintain access and renegotiate it horizontally and vertically

9. Focus Group The facilitated interaction of several individuals simultaneously, focusing on a particular topic or theme • Background – market research, politics • Generate qualitative data • Defined focus but no need for agreement • Experiences, perception, attitudes, emotions • Group interaction; dynamics between participants • People can change their minds

10. Some current themes on leadership Leading and Managing

11. Leadership, management and authority • Hierarchical authority • Professional authority • Reputational authority • Personal authority • …

12. Leaders and Managers Some key differences: • Attitudes to change, restlessness, turbulence. • Attitudes towards efficiency and waste • Attitudes towards details and grand picture • Emphasis on logic, plans and rationality as against hunches, intuition and gut feeling • Inspiration versus deals

13. Some current issues on leadership • Are we still dominated by images of leadership concentrated at the top? • Are we underestimating the caring, containing and protecting dimensions of leadership? • Are we expecting too much from leaders? • If so, why?

14. Leading is …imagining, willing and inspiring

15. Some preliminary impressionistic findings • Clinical versus managerial leadership • Charisma • Persuasive (and pushy) • Team player • Responsibility • Caring (and pushy) • Present (approachable, available and responsive) (“He is always absent. I never find him when I need him. He is never there. This happens on a daily basis. So there is an absence of leadership.”Consultant)

16. Clinical and Managerial Leadership • Clinical leadership • Responsible • Persuasive • Have patients’ interests at heart (care) • Make good decisions • Managerial leadership • Often noted through its failures, e.g. cancellation, shortages and bottlenecks “It is managers who cancel operations, but the doctors who must then inform the patients of the decisions. Many of the cancellations are due to inflexible rules on breaks.” • Rotas, quotas and targets to ensure consistency “We work very closely with guidelines and protocols, which does enable you to have a standard and that’s the most important thing that we all work towards the same standard.”

17. An example – clinical leadership and patient care “A pregnant woman came in through A&E. She was having problems with her pregnancy. I asked the registrar what to do. They decided that the best thing to do was get the woman scanned to find the problem. However, being a night shift there were no porters to be seen and the scanning units were closed. I felt that the anxious woman could not stay in A&E surrounded by drunks and druggies as it was inappropriate. Instead of calling for porters, which would have taken time, I and the registrar moved the pregnant lady to the maternity ward ourselves where we opened up a scanning unit to find out what was wrong with the lady’s pregnancy. I was proud of the leadership that I had received from my registrar; not every registrar would have done this but he solved the problem and delivered good patient care in the process. The problems were resolved within an hour with only skeletalnight staff.” (Junior doctor)

18. Patient care • Predominantly in clinical terms • Personalized (sometimes be flexible about rules) • ‘Going the extra mile’ • Continuity of care, teamwork (and yet …) • patient care stems from professionals helping each other (unspoken alternative being that professionals do ‘their bit’ of the job with scant regard about what will happen to the patient next). • To a lesser extent choice

19. An example – on choice as a feature of patient care “Flexible patients are better. It becomes clear when stuff hits the fan, for example a lady who had all the information but still wanted to consult a non-medical outsider, or a lady who did not want a doctor in the room, just a midwife, and had complications and ended-up having five doctors in the room.” (The group laughs enthusiastically).(Junior Doctor)

20. An example – patient care failures “Every clinic, every single clinic I send somebody home because the notes aren’t there at all. They are supposed to be coming to see the consultant and he’s not there, and they’ve been put into my clinic and you look at the letter and it clearly says on the letter, “consultant only to see”, and they turn up and he’s in Italy, on holiday, and you have to go out and say, I know you’ve waited three months for this appointment but I’m afraid the consultant is not here and he wants to see you personally, so thanks for coming but if you can just go away and, you know, you can’t even say to them you’re getting an appointment for next week because realistically they’re getting an appointment in three months time, and I think that’s really disappointing, I feel very disappointed in the system, which, I know the system is a big wide thing, but you don’t really know what you just pointed with but I think let people down.” (Registrar)

21. Examples – distributed leadership “Leadership doesn’t have to be defined as a ranking position, such as consultant, registrar, senior house officer, or midwifery leaders, leadership may be individually - a porter may take leadership initiatives and run with something and do something that that then involves the rest of the department and that is leadership.” (Consultant, OBS&Gynae)“I think, there was one time when of a misjudged situation the patient very nearly died, and I got called and other people got called. The leadership in terms of those people who turned up to deal with this situation from their different aspects, and kept her alive, otherwise she’d be dead, I think it was very good indeed. It was a good example of different people coming and taking leadership role in a situation and pulled her through and its fine. A lot of difficulties. As a result of different people taking leadership in the situation very calmly at different times, patient survived to tell the tale. But that was an acute situation of leadership that went well, despite problems.” (Consultant, OBS&Gynae)

22. Another example – distributed leadership Interviewer: “And what leadership do these people [junior to you] bring to you?”Senior consultant: “I suppose I probably better talk about the nurse first of all because she came at a major time of change where three different physical venues were being amalgamated into one. That meant that quite a lot of [whispers – aside] how would I put it? cross wouldn’t be quite the right word [normal pitched voice] but disgruntled staff who saw that this is my bit and I don’t want to go there, so she had to manage all of that, getting people on board as well as actually getting the department kitted out, and she managed that extremely well, bearing in mind that particularly she was new to the service too. And this has been going for about, I suppose 6-9 months and [whispered voice] and that seems to be going ok. But I would have to say I think that she has managed it better than the doctor, who perhaps would have otherwise been cast in that role.

23. An example – ‘empowerment’ (delegation, support, trust, being there if needed) “Leadership is actually giving, empowering people to make decisions… I think the most important thing is that you provide as much as you can one-to-one care and be available for any, if the midwife needs any sorts of support, wants to run anything by you, “I’m a bit worried about this one, what you think I should do next?” then that’s part of my role as well. It’s almost teaching role, it’s a supportive role, it’s getting them to empower, empowering them making their own decisions, making them feel that they’ve got the support to do that.” (Clinical Manager, Maternity Services

24. Some concluding reflections on care • Care as a bridging concept between leadership and patient care • Care as individualized concern • Care as ability to push hard and engage in conflict in pursuit of the cared for • Care as willingness to ‘go the extra mile’, to bend rules and to not give up • Care as a powerful fantasy whose frustration causes deep resentment and disappointment

25. Ephesus – Library of Celsus The four virtues - goodness, care, knowledge and wisdom goodness, care, knowledge and wisdom

28. School of Management SEMINAR