CURRENT CHALLENGES FACING MEDICINE AND MANAGEMENT

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CURRENT CHALLENGES FACING MEDICINE AND
MANAGEMENT 29th May 2007 Dr. Tom Frawley
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• May you live in interesting times
• - A Chinese curse

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Uncertain times a context

• Bristol Royal Infirmary
• Dr Harold Shipman
• Beverley Allitt
• Dr Michael Neary
• Sperrin Lakeland
• Organ Retention
• Endoscopes
• Mammography United Hospitals

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Choice

• How to behave
• Survival
• Adaptation
• Skills
• Learning

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The Patient-Doctor Contract

• In the past
• They give their time, training and expertise and
  expect in return to get autonomy, deference,
  respect and job security
• To give and get

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The Patient-Doctor Contract

• Now, however
• Greater accountability, more assertive and
  better informed patients, a need to collaborate
  with other professions, and constant evaluations,
  inspection, audit and even regular reviews of
  their competence to practice

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Clinical Interventions

• Maintain Life
• Restore Health
• Prevent harm
• Reduce Risk
• Enhance safety
• The Reality - harmful consequences are more
  common than we recognise
• 10 in-patient admission adverse event
• 5 population report adverse effect of medical
  care
• 18 of patients report being victim of medication
  error in previous 2 years
• Manage expectations

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Medicine A Challenging WorldSir Brian Jarman

• 240,000 out of 610,000 deaths some 40 - occur
  in hospital
• 12 - some 28,000 of these hospital deaths
  caused by avoidable adverse events
• Large (4x) variation in death rates between
  hospitals
• Best 400 fewer than average
• Worst 200 more than average
• Where is Northern Ireland/Irish Health Service?
• Where is your hospital
• Where is your specialty

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England Wales Health Service Performance

• People gain access to services more quickly NHS
  Direct and walk-in Centres
• People waiting more than six months for admission
  as In-patient - down by 85
• Drop in number of people waiting more than 13
  weeks for an appointment as an Out-patient down
  by 92

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England Wales Health Service Performance

• Improvements in outcomes of care and treatment
  for people with coronary heart disease or cancer
• Mortality rates for cancer have gradually
  decreased
• More than 50 of people who have a heart attack
  receive clot busting drugs within an hour 84
  receive them within 30 minutes

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Healthcare Commission Survey of NHS Patients in
England (May 07)

• 93 said room or ward clean or very clean
• 84 said they waited 6 months or less for planned
  admissions
• 20 of patients who needed help eating said they
  did not get enough
• In 30 Trusts 20 rated the food as poor in
  most other trusts few rated the food as poor
• In planned admissions, not to critical care
  units, 11 said they shared a room or bay with a
  patient of the opposite sex
• How would the Republic of Ireland perform?

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N.I. Health Service Performance

• Hospital activity per member of staff 19 lower
  than UK
• Hospital activity per available bed 26 lower
  than England
• 43 more admin staff than in England
• Average unit prescribing costs 30 higher in NI
• Significant variations in unit Trust costs in NI
• Major variations up to 25 in allocated to
  communities in NI
• Considerable unused capacity, for example, in
  operating theatres
• R.O.I. Health Service Performance?

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• Need for greater scrutiny, medicine used to be
  simple, ineffective and relatively safe. It is
  now complex, effective and potentially dangerous.
  
• The mystical authority used to be essential to
  practice. Now we need to be open and work in
  partnership with our colleagues in health care
  and with our patients
• Cyril Chandler,
• Dean of Kings College Medical School

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LEADERSHIP AND MANAGEMENT
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Shift Happens!

• GREATER SUCCESS
• at GREATER SPEED
• with CONSTANT UNCERTAINTY
• with LESS RESOURCE
• with MORE COMPETITION

• Our world of work
• Who wants to play?

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Unprecedented Change
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Positive Drivers of Change

• Changing Public Expectations
• Patient Knowledge (Internet and Media)
• New and improved technology
• Patient Choice
• Additional Funding

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Public criticisms

• Public criticism of clinical professionals
• Tolerance of poor practice
• Secrecy about professionals performance
• Poor communication
• Paternalism
• Insufficient accountability
• Regulation not sufficiently open and transparent

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What the NEW PATIENT expects

• Accessibility
• Knowledge generalist and specialist
• Skill holistic approach
• Empathy
• Care
• Effectiveness
• Leadership

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What the NEW PATIENT deserves

• To be treated as a partner
• Not to be seen as compliant and submissive
• To be given the information required for truly
  informed consent
• Thoracic surgery example.

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The Patient Perspective

• Patients a sense of
• Powerlessness
• Frustration
• Fear
• Culture eats strategy for breakfast

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• The experience is the outcome Hardwire patient
  experience
• Hitting the targets Missing the point
• Archie Cochrane Rocking the patient
• Listen Spend time Hold hand

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Neither a brave man nor a wise man lay down on
the tracks of history to wait for the train of
the future to run over him. Dwight D
Eisenhower
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Is everyone a Leader?

• Those who make things happen
• Those who think they make things happen
• Those who watch things happen
• Those who wondered what happened
• Those who didnt know anything happened

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Leadership Competencies

• Strategic awareness
• Customer orientation
• Quality creativity
• Ethics
• Individual accountability
• Team playing
• Communication skills

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Leadership

• Is difficult to define - virtually impossible to
  measure objectively and cannot be taught in
  schools
• However, the quality of leadership is the most
  important ingredient in the recipe for the
  success of an organisation
• It is the ability to inspire other people to work
  together as a team, following your lead, in order
  to attain a common objective

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Leadership

• No one can do it all alone others must want to
  follow the leader
• Leadership is learned - the ability to lead and
  inspire others is far more instinctual than
  premeditated and is acquired through the
  experience of everyday life

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Leaders v. Managers

• The manager administers
• The leader innovates
• The manager has a short-range view
• The leader has a long-range perspective
• The manager asks how and when
• The leader asks what and why

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Leaders v. Managers

• The manager has his eye on the bottom line
• The leader has his eye on the horizon
• The manager accepts the status-quo
• The leader challenges it.
• Warren Bennis

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The Essential Tasks of Leadership

• Tune into the environment, see need,
  opportunities Encourage curiosity that opens our
  eyes to new possibilities not just about problems
• Be dissatisfied, generates fresh thinking.
  Creativity, find new approaches, dig beyond where
  we are, identify new possibilities, approaches

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The Essential Tasks of Leadership

• Anticipate a vision that will mobilise people to
  act. Change begins with hope. Get other people to
  see it too. To pilot is important dream. Small
  steps important.
• Coalition building, cross boundaries water
  walkers need stones

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The Essential Tasks of Leadership

• Find, recruit, identify the team that will make
  it happen. A dream needs to brood.
• Persevere until you wear down the middles have
  passion. You can run out of time and money.
• Forecasting is difficult if you are doing
  something unique.
• Run into obstacles. People get tired, that is
  when critics emerge.
• Separate lines.

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Leadership is Key

• Leaders must ignite
• Passion
• Pace
• Drive
• Leaders must Build Common Purpose

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Drivers for Todays Workforce

• Emotional being involved in ones work
• Cognitive focussing hard while at work
• Physical being willing to go the extra mile
• Engaged Staff Feel positive about job Perform
  better

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The Essential Tasks of Leadership

• Make heroes of everyone, appreciate, recognise
  and acknowledge everyone. Say thank you. No one
  wants leaders, they rise also to the challenge.
  Energy
• Communicate, communicate, communicate

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Staff -

• Follow Leaders because they want to
• Human beings powered by emotion
• Ambiguous Leadership

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Managing Informal System

• Dolly the Leader
• Nurses in charge of mood of patients
• Cultural Blackspots dominated by harassment
  and bullying

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• AN EFFECTIVE COMPLAINTS SYSTEM

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• Complaints
• Real time insight.

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Building an Effective System

• Focus on rights of Patients
• Right to safe treatment
• Importance of good record keeping
• Importance of good communication - Between
  Clinical staff - Between Clinical staff and
  patients/ families

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Acknowledging Mistakes

• Openness is a precondition for learning
• Complaints, changes and mistakes are logged and
  replayed
• Mistakes are acknowledged, even celebrated as a
  source of information
• Everyone does better in future
• A learning organisation develops

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In Summary

• A whole system
• Strong compliance to a uniform system
• Rooted in local resolution
• Independent 2nd level other than body
  complained of
• Ombudsman final recourse

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An Effective Complaints System

• Easy to access
• Fair
• Flexible
• Ensure confidentiality
• Clear and
• Timely
• Integrated with other systems to provide
• Valuable Feedback and
• Engender trust from service users and staff

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10 Tips for Dealing with Complaints

• Keep it simple
• Use the phone more dont automatically write
• Find out what the complainant wants you to do
• A quick apology can be better than a long letter
• Give personal and specific replies

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10 Tips for Dealing with Complaints

• Follow the mother principle
• Dont pass the buck
• Be clear what solutions you can offer
• Let people know about improvements you make as a
  result of complaints
• More complaints can be good news! It shows your
  customers trust you to take them seriously

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The Rights Responsibilities of Complainants
Key elements of an effective complaints system
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The Core Values That Inform Our Work

• Independence
• Integrity
• Impartiality
• To give life to these core values we treat people
  with courtesy, consideration and honesty And
  respect their privacy

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Benefits of effective complaints system

• Identifying areas for improvement
• Creating a second chance to provide the service
  and satisfaction to dissatisfied clients
• Leading to.
• Strengthening public support for the system of
  public service delivery

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Designing Effective Complaints Systems

• Go the extra mile
• Make the service personal
• Deliver on promises for the system
• Deal with complaints as well as we possibly can

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Why we need complaints systems

• Working in the PUBLIC service means
• Accountability
• Especially to those who are dissatisfied
• People have a RIGHT to complain
• Responsibility
• People do not have a choice
• Guard against insensitivity

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Why we need complaints systems

• BUT it doesnt mean
• We are immune to changes in society
• People may not have choice, but they do have
  expectations
• Expectations are changing

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Why we need complaints systems

• Change in Public Expectations
• Accessibility and choice
• Responsiveness
• Effectiveness and safety
• Openness
• Transparency
• Increasingly comparing public sector service with
  private sector service

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Why we need complaints systems

• Change in Government Policy
• Readiness to adopt radical solutions to issues of
  service delivery
• Public Sector may be guaranteed first crack at
  solving problems, but what if fail?
• Increasingly looking to private sector for
  solutions to public service delivery

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Why we need complaints systems

• Old borderlines are evaporating, old categories
  are merging. The divisions between commercial,
  public-sector and non-profit organisations are
  becoming blurred. All organisations now act on
  the same stage, and need to justify their place
  on that stage.
• The Big Idea Robert Jones

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Why we need complaints systems

• So why do we need complaints systems?
• Because we are obliged to be accountable
• Because society is changing
• Because Government policy is changing
• BECAUSE WE NEED TO UP OUR GAME

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Accountability

• Accountability must be provided to citizens and
  users of public services, especially those who
  are dissatisfied
• Citizens and users have a right to complain
• Accountability- a complex and multifaceted
  concept
• More than discharging responsibility

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Accountability

• If actions to obey instructions- to be
  accountable requires only the report that these
  instructions have been obeyed
• If actions require the exercise of discretion (to
  make choices, take decisions)- to be accountable
  also requires an explanation

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Accountability

• Public officials are accountable for
• the results or outcomes of their actions
• the professional standards of their work
• the effective use of resources, including
  financial resources
• If users of system feel service has fallen short
  of expectations- system needed to address
  deficiencies
• Complaints system

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The Importance of Ethics

• Ethics must inform all of the fundamental values
  that determine our professional and personal
  behaviour
• Ethics is concerned with
• honesty
• fairness
• justice
• respect for others
• making us think about the impact of our behaviour
  on others and, by extension, our reputation

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The Importance of Ethics

• Shouldnt see ethics as a ring-fenced boundary
• Not a set of mechanical, abstract rules to be
  wheeled out and applied to some abstract
  circumstance
• For our discussion is about no ordinary matter,
  but on the right way to conduct our lives
• Plato

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The Importance of Reputation

• Reputation is a precious commodity
• Takes a lifetime to build, can be destroyed in a
  moment
• Once reputation is lost, it can be incredibly
  difficult to rebuild, if not impossible

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Key issue - risk to reputation

• Common theme from case studies where reputation
  is lost denial (Randall 2007)
• Typical chain of events leading to reputational
  catastrophes (Wharton School, University of
  Pennsylvania)
• Theres an initial mistake, often minor, that
  goes uncorrected
• A subsequent error compounds the initial error

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• Attempts to correct the problem are often
  half-hearted, either because there is no
  recognition of the increasing seriousness of the
  situation, or executives are in denial
• When the problem eventually becomes too big to
  ignore, attempts are made to hide the truth and
• There is an awful moment of acceptance that the
  situation is completely out of control

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Words to live by
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• I Have Seen the Enemy
• And He Is Us

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• A belief that what we are doing is important
• An empathy for the people we work with and work
  for
• The certainty is change
• A sense of humour

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• When You Point Your Finger At Someone There Are
  Three Fingers Pointing At You

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• Things Do Not Change
• We Change
• Henry David Thoreau

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Final Thoughts!

• Nothing in life is certain
• The public is often (very) demanding
• Those with the least to complain about often
  complain the most and those with the most to
  complain about often complain the least
• Simple courtesies can make a big difference and
  the word sorry can transform the circumstance

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It should be borne in mind that there is nothing
more difficult to arrange, more doubtful of
success, and more dangerous to carry through than
initiating changes in a States
arrangements. The innovator makes enemies of
all those who prospered under the old order, and
only lukewarm support is forthcoming from those
who would prosper under the new Machiavelli