The artistry of leadership

There is an artistry to effective leadership.

Expression changes everything.

This post by Garr Reynolds speaks more eloquently than I do.

The fine ART of management

I am blessed that currently I work in an institution that gives me many opportunities to reflect on different management styles. A further blessing is some insightful and gorgeous friends who stimulate and support my thinking and development.

Take a look at this piece of art. I love it.

Sinister Rainbow, Emma d'Souza (medium- acrylic, silk thread & felt)

Is it just paint splashed around? Is the artist authentic ? Does it encourage other people to come and look at other pieces of work? Will it influence others? Will you look at your own work and want to do better or differently next time? Could the artist explain why? Would you be proud to display or own this piece of art? Is it art?

I believe the same questions can be raised of management style.

I’m sure, with the right materials and time I could attempt to produce something like that. But is that art? Is it just the finished article we are looking for? Is a poor copy worth the same? Surely what is more important is the journey to that end point.

We all have to accept that targets are met, roles fulfilled, projects planned and appraisals achieved but surely (please?) what is actually more important is not the end point but the nature of the  journey in getting there. There has to be more art to management than simply administration.

Her Majesty’s Opposition

As the political conference season draws to a close, a colleague of mine made the point that clinicians within the hospital Consultant Medical Staff Committee are analagous to the political opposition.

Considering and extending this I believe it does offer an interesting view as to the different roles clinicians may play in the management of the hospital.

Some are directly involved in committees of power although restricted in their ultimate influence by not being a member of the ruling party. Some exert influence through lobbying using skills and contacts developed over time. Sadly others engage purely in “yaa boo” politics attempting at every step to block and criticise the party in power.

Ultimately the role of the opposition is to hold the government to account because without them the government would not be responsible or effective for society as a whole. Clearly however the two sides hold very different opinions and philosophies over how and why things should be done but both, whatever our personal feelings, are actually striving for the greater good. Issues about election would be interesting to explore!

(Quite pleased in being positive again!)

tell me something positive please?

I’ve had a bit of a rough week with our management team. I wrote a post and decided against publishing it as all it reflected was my negativity.

So I thought, why not seek out some positivity? Let us all (as there are regular visitors to the site) hear your encouraging stories of management, clinical leadership and how it works for you. Share how you can see how things are improving or where change has happened for the better.

Go on, let’s hear the up side?

It’s not what you say, it’s how you said it!

A phrase guaranteed to strike a chill in the heart of anyone who has ever heard these words.

The recurring theme on this blog and the probable theme of my dissertation is the engagement of clinicians and management. I regularly bemoan the state of this interface and long for improvement. Some would suggest my view is biased and I have tried to reflect on this and question why it should be that some believe there is effective interaction and yet others disagree.

On the one hand Staff Surveys, Clinical Leadership Engagement programmes, such complex human resource terms as High Performance Work Systems (HPWS), Chief Executive Briefings and even open staff meetings such as “The Big Conversation” show a significant desire and investment from management in finding out what staff actually feel about the organisation within which they work. On the other hand is the negativity and lack of interest show by significant numbers and elements of staff towards such initiatives. When I personally consider the relational coordination as described by Hoffer Gittel it leaves me cold as our unit, department and organisation fail (from my perspective) across all seven criteria.  Clearly the signals that are being put out are not those that are being received.

The failure of each side to effectively engage with the other is not due simply to lack of available avenues of discussion. There are many contributing problems such as deeply held beliefs and suspicions; hurts and barriers from previous experiences; misunderstandings and mistrusts; all have so tainted the relationship that despite there being opportunities for rapprochement, neither side can really make any headway.

This is made worse by fundamental attributional error: “everything” is the fault of “management”. This might be lack of car parking spaces; the peeling paint in the theatre changing room; decisions regarding resource allocation in oncology; appointment of  junior service managers or even the corporate logo; everything bad appears to be blamed upon “management”. Consequently, whether such actions were valid or not, there is direct allocation of blame, with its implicit presumption that such actions and all future actions are examples just the “sort of thing that management does.”

And so we are doomed to follow this path towards permanent mutual resentment until each side effectively engages with the other. Is that a consumation devoutly to be wished?

Somewhere over the rainbow…

Is it a fantasy? Is it a dream? Is it a story of a search for missing characteristics? Is it possible or is it even Kansas?

In preparation for my recent essay I came across the Really Learning Website and a “subjective think piece” written by Valerie Iles that explores the introduction of management into the NHS over the last twenty years, its relative successes and alternative approaches.

The piece is insightful, thought provoking and challenging. You should read it. It finishes with a paragraph that summarises much of what I have blogged about over the last few months.

“As we challenged our assumptions we might also recognise as fundamentally flawed the notion that any management consultant or policy advice team is better at devising structures and processes for the complex, dynamic interdependent set of systems, that together comprise our national health care, than are the people working within them. It is not Roy Griffiths’ fault that his prescription took the system as a whole in the wrong direction for 20 years, but we must make sure we never again allow one person’s view  to prevail. We must find ways of allowing locally relevant solutions to develop and flourish, devised, owned and implemented by local teams of clinicians and managers, held to account only for their outcomes and not for implementing a centrally prescribed set of processes. “

It wasn’t The Wizard that changed things.

When the shit hits the fan.

In the European Grand Prix at Valencia this Sunday the Maclaren Mercedes of Lewis Hamilton came into the 2nd pit stop with a 4sec advantage over the second place car of Reuben Barrichello.

Working as a slickly oiled machine the car went up on the jacks, the wheels came off, the fuel pump went in and…then they realised there were no wheels to go back ON the car. After what must have seemed like an eternity the spare set of boots came out of the garage and were fitted. Presumably behind that protective gear there were a few red faces. Following his pit stop Barrichello won the race by 2.3 secs.

Looking at the result we can see Barrichello’s pit times were 8 sec shorter than Hamilton and when Hamilton entered the pits he was 4 secs ahead of Barrichello. Interesting maths.

Interviewed immediately after the race the team principal Martin Whitmarsh when asked specifically about the incident said, “It didn’t affect the outcome of the race…we lost the race because we weren’t quick enough (on the track).”

Interviewed immediately after the race, driver Lewis Hamilton refused to allocate blame to the pit crew and said, “We win and lose together… these things happen.”

When the stuff hits the fan most adults fully recognise their error. It is not always necessary to specifically or openly point it out; those with insight hopefully learn. Sometimes leaders attempt to protect the reputation and “feelings” of a team by publicly sidestepping or even denying problems. Other leaders openly accept the problem, avoid blamestorming, and unite the team in moving forward despite the problem.

Was there really a problem? Did it really affect the result? How is the reputation of the team affected by each approach? Which leader would you prefer to lead your team?

Docendo discimus – we learn by teaching.

Some positivity today.

I am privileged to work alongside some very talented people including anaesthetists, surgeons, physicians, nurses, radiologists, administrators, and technicians. I believe one of the most important things these people do is not the individual roles that they perform but the passing on of that expertise to allow others to do the same.

There are few out and out geniuses, whose talent and production is so special that it must be considered a gift of some higher power and cannot be taught. The rest of us have been nurtured, admittedly from variable starting points, but we must all accept that few of us are where we are today without the supervision and support of someone who has gone before.

I was prompted by an email to remember one of my teachers and as I teach and encourage myself I see the truth of what Seneca the Younger said, “Docendo discimus (we learn by teaching)”. The value is immense; it shares and develops many but the reflexive nature develops the teacher too.

This I think is an essential of many jobs but none more so than in leadership.

#welovethenhs

Few people can have missed the American Republicans’ disastrous approach to the healthcare discussion straying beyond normal political posturing into farce, exaggeration, lies and the plain ridiculous when it comes to using the NHS as an example of how bad healthcare can be. One of the expressions of annoyance at this criticism of the NHS has been a spontaneous twitter campaign #welovethenhs, even supported by the Prime Minister himself.

But I believe there is something we can learn from American healthcare.  Am I aligning myself with Conservative “maverick” Daniel Hannan? Not in the slightest. My point is to echo a line from a paper by Reinertsen (2007) at The Institute for Healhcare Improvement. They have tried to address some of the difficulties in engaging clinicians in a quality agenda and ways to improve it. I have to confess to having a physical reaction on reading this paper, which for me and management science must count as a first:

 “Administrators need to stop regarding clinicians as customers and start treating them as partners in the delivery of healthcare.”

There is a lot clinicians have to learn about management and the whole topic of engagement I suspect will never be fully analysed. I accept there are dramatic differences in funding and organisation (sic) of American healthcare but this I believe is something they have correct.  I believe it sums up a fundamental difference that both offers solution and defines some of the difficulties. Clinicans are not overspending budgets, failing to make cutbacks, having shortfalls in clinic returns rates. Clinicians are dealing with patients. With the patient at the centre of this debate and the ONLY reason for the service being there each side may stop regarding the other with suspicion and regard each other as partners in the delivery of healthcare.

The reasons why we are currently at this juncture may contribute to our learning and progress from here. That I suspect will be my thesis.

Reinertsen, J., Gosfield, A., Rupp, W., & Whittington, J. (2007) Engaging physicians in a shared quality agenda. Institute for Healthcare Improvement, Cambridge, MA.

All is not as it appears.

The recent gap in posting has been partly due to the large amount of work I have been putting into our degree assignment. This morning I (hope I) put the finishing touches to the wee beastie and popped it in a zip file. My paper is on “Engagement of clinicians and management in the NHS” and after considering the issue in terms of organisational structure, strategic planning and clinical leadership I do think I have some useful thoughts.

One of the principal causes of poor engagement is that, contrary to the Mintzberg classification of organisational structures, hospitals (or ours at least) are not being run as the professional bureaucracy that the clinicians expect but as a machine bureaucracy.

I appreciate that for some of my readers I might as well be speaking Polish but I am also encouraged that many people read this who are not approaching the topic from an in depth study of organisational taxonomy and yet show an interest and insight. I think it helps me to try and explain this (to myself) in different terms so I will try and do the same for you.

In a managed professional bureaucracy the “operating core” (clinicans) are the source of production and because of the specialised nature of what is produced (clinical care) the core have a large degree of autonomy, control over performance and are supported in this by the “strategic apex” (management).

A good example of a machine bureaucracy would be a factory with highly specialized, routine tasks; formalized procedures in the core; a proliferation of rules, regulations, and formalized communication throughout the organization.

Unfortunately, in the modern NHS the latter rings more bells than the former. Drives for performance, merged and centrally managed waiting lists, cross covering, out-sourcing, the lack of core professionals  influence or even be involvement in strategic planning, imposition of “guidelines” and “protocols” may be viewed as a move away from the autonomy and professionalism expected of a managed professional bureaucracy.

Bate proposes changing the culture of a hospital as the “experiment” of clinical directorates has failed. He may be right. What is sure is that the current structure is not as the operating core would like, nor as Mintzberg suggests it should be. Perhaps this partly explains the lack of engagement between clinicians and management.