Perspective is all

25 05 2011

Our department is being faced with some significant changes and we have, for the last few weeks, been struggling to find any opportunity that we might meet to enable appropriate feedback to the senior management in the organisation. It has proven almost impossible for the six of us to find any time within our already busy calendars, including early mornings and late after work, to meet.

Last week when I returned to my car in the hospital car park I found my car blocked in by two cars. There is never enough space and this is actually fairly accepted local practice. Our permits display contact details so we can be contacted, nip out and release trapped colleagues. I telephoned both owners who both agreed to come straight away and let me out so I could to the peripheral clinic that afternoon. As luck would have it the owners of before I had the chance to leave my office and car 1, in her haste, allowed car 2 out and quickly re-parked (keeping me blocked in) and ran off. I arrived literally 10 secs after her departure. With a heavy heart I telephoned her again explaining that my car remained blocked by her and I would need her to return so that I could go to my clinic. “I’m afraid I can’t come; I’m in a very important management meeting.”

It struck me then the differing perspectives on “management meetings”. As clinicians, we have no time whatsoever set aside within our schedule for something that is actually essential to the functioning of our unit. It is not considered a priority in the job planning meeting that such meetings should be timetabled and yet a management colleague believes that her time at a management meeting is so important that she cannot spare literally five minutes to release a colleague trapped in the car park.

Surely we could learn something from each other? Effective clinical engagement can only occur if management discussions are given some priority within the clinical job plan but realistically, just how important can a meeting be that you would leave a colleague trapped in the car park?


A Love Supreme

20 10 2010

In case anyone was wondering- I passed!  My thesis was accepted and now I am a Master! And yet I recognise I’m not, I shall always be insei, rather than sensei.

I shall blog more of my thesis over the next few weeks but perhaps my most insightful moment I had was one day from the deadline when I stumbled into an analogy that helped me (at least) have an understanding of clinicians and their work and the interaction with this by management: clinicians are in love with their work.

The intensity, depth and true nature of that love is variable as is the love of ice cream, a football team or for a child. It is a relationship that has potentially spanned over 30 years since beginning as medical students and may have been desired for years ahead of commencement. This is no one night stand. The love relationship is completely individual and deeply personal.  Clinical practice, a reflection of the individual clinician in their beliefs, character and skills is the outward expression of that love. Clinicians will go many, many extra miles for their love, put up with many disappointments and hurts simply to maintain their love seeking their reward principally from their love. Whilst it would be naive to suggest clinicians would work for free, the majority would report that their reward comes principally from their practice not their employer.

This is the reason for the poor engagement between clinicians and managers.

Clinicians are in love with their job and view external influences upon this relationship the same way any one of us would view external interference upon a personal relationship. Similarly suggestions by external agencies of measurement or efficiency of this relationship are met with disdain. The validity of the conceptual position may be questionable but the analogy allows understanding of the difficulties encountered. The different realities and understandings of clinical leadership may be understood by use of  the analogy. Clinicians regard effective clinical leadership as that which facilitates the development of their individual love relationships in stark contrast to the managerial directive and restrictive expression of leadership.

Engagement can be seen as the evidence of the love relationship. Importantly this engagement is with either patient groups or a clinical practice and not with the greater organisation as is desired by the unitarist view of management. It should be clear that this love relationship is monogamous. As such, blundering attempts at “engagement” by another suitor in the form of forced appraisal, insincere “conversations”, imposition of “core values” and attempts at corporate branding are seen as cheap as garage forecourt flowers.

The astute amongst you will recognise the photo in my avatar and the connection with the title of this piece. Regarded by many as one of the greatest jazz albums ever, “A Love Supreme” by John Coltrane is an expression of love and thankfulness. It is at times impenetrable, at others openly joyous but all the while a deeply personal reflection and expression of love. Can you imagine the engineer stopping Coltrane half way thru’ and telling him how it could be played more efficiently, with less notes?

I had a dream

27 07 2010

What is it about dreams? They are weird places where exciting, gorgeous, impossible, frightening and some would say telling things happen. I have a few recurring dreams: my stress dream of not being able to run away properly due to a muscle injury and  my happy dream that I can fly.

So what, you are rightly asking, does this have to do with “a learning journey into Clinical Leadership”? Well, I am currently writing my thesis for the Masters and I suspect this is why my head is full of thoughts struggling to escape or find order depending on one’s view of the universe. This morning I was having the weirdest of dreams but, just as I awoke, I had the most amazing moment of clarity: the reason I don’t want to be a manager is that I can’t make it work, it is a wicked problem.

Let me explain that this is a reasoned argument, based on current leadership theory and not just casual street speak either. innit!

Grint, in an oft quoted but exceptionally difficult to source monograph, “Wicked Problems and Clumsy Solutions” explores the reasons why most change initiatives fail and suggests that “this failure might be more to do with our framing of the problem and the consequent approach to resolving it.” He goes on to look at the nature of problems and the leadership approach most suited to dealing with these.

Essentially there are three situations for which we seek guidance from authority. (I am trying to avoid using phrases like management and leadership until the concept is clear.)

The first are those extreme and urgent situations, such as a fire or fight, where, what is needed principally is simply a decision. Ultimately that decision may not be perfect, it may not be the best thought out but what is required is immediacy and action. From that movement further action may be taken in a more structured manner. Grint classifies this as a “Critical” problem for which we look for Command and Control style direction.

A problem for which there is clear solution, however complex that solution may be, is classified as “Tame”. Essentially a puzzle, there is a proven and effective approach that the use of management strategies can offer resolution.

Lastly there are conditions for which there are no solutions, a “Wicked” problem. Importantly, this is not due to the urgency or complexity of the issue but essentially, because it cannot be removed from its milieu to be analysed and solved, it is unsolvable the use of either Command and Control or Management approaches. What is required is, as termed by Grint, a “Clumsy” solution, recognising that the problem cannot be solved but must be addressed by a less than perfect solution cobbled together by the collective minds. He uses the analogy of the “bricoleur” a do-it-yourself craftworker who makes do with what is available rather than seeking the answer of perfection and design. Grint proposes that the searching for the perfect solution (viewing the problem as tame/solvable) is part of the problem and the leader’s role is ” to ask the right questions (of the collective) rather than provide the right answers.”

So, back to my moment of clarity, my waking dream. My life and training is about fixing things, small children in particular and cobbling together a clumsy solution for wicked problems just doesn’t fit with that. I can see people who would revel in such activity and they should be the ones to facilitate the rest of us in our collaboration.

Now, of all the dreams we can have, including those ones, to wake up de-constructing leadership theory is not what I live for. My Prof may or may not be impressed but there you go, it’s part of my journey.

The fine ART of management

27 10 2009

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

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

6 10 2009

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!)

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

21 09 2009

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?


17 08 2009

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.

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