Dispersed and mandated clinical leadership
Circle Health Ltd.
Ghost-writing for Dr Massoud Fouladi
In the wake of the Francis Report and its predecessors one question remains unanswered: who are the leaders that will implement the changes set out in these reports?
To achieve better care for patients there are three steps that require implementation: learning around epidemiology of disease; sociology of change and a new facilitative leadership structure.
In UK healthcare there is no shortage of knowledge on best practice guidelines or epidemiology of disease. This knowledge is used to translate evidence into better care for patients and comprises the first stage on the journey of implementation. In seeking genuine change for our healthcare system we must focus our efforts on the remaining two steps: sociology of change and a leadership structure that allows the defining behaviours of leaders to drive cultural change in an organisation.
Healthcare costs account for a significant portion of GDP spending in any developed country (9.6% of UK GDP in 2010). With an ageing population and expensive innovations, this proportion will only increase, bringing with it a growing impact on the rest of the economy. As a result the health system will stay under the scrutiny of the Treasury as it seeks effective ways to controlling the spiralling costs. In turn, this drives centralised decision making and planning to allow government bodies to keep a tight grip on spending. In the UK 90% of healthcare professionals (equating to 1.5 million staff) are within this tight financial grip.
Against the backdrop of this challenge, how can we expect local organisations, whether CCGs, GP Practices or Hospitals, to run devolved models with local autonomy? Coupled with this comes an even greater challenge: how to achieve dispersed clinical leadership, in a hospital setting, which simultaneously empowers professionals and holds them to account.
We do not have all the answers but from our own experiences, and the parallels with similar organisations, we know that transformational change has a number of distinct features. We believe that healthcare organisations are professional services, which need autonomy like any other professional service such as legal services or accountancy. In addition to this autonomy parts of transformational change in culture and leadership are process driven. This process-rich side to healthcare can benefit greatly from operating models from the manufacturing industry (such as Toyota) to drive business excellence.
The Circle Operating System combines both sides: professional autonomy and effective process-driven models. Through this we devolve power to front line clinicians within departments known as Clinical Units. These Clinical Units have a leadership triad of a Doctor (Clinical Lead), Nurse (Lead Nurse) and manager. In conjunction with this clinical leadership model, we have developed our own operating system as a methodology to achieve business excellence on a level described by Stephen Spears in his book on High Velocity organisations.
Within this model our hospitals are run by Executive Boards with a large membership of clinicians to enable us to make radical changes to traditional healthcare organisational structures. In Hinchingbrooke our Executive Board includes seven Clinical Leads mandated to represent the views of their respective Clinical Units. The CEO, COO, CFO, Director of Nursing, Director of State and Hospitality, RO and Clinical Chairman sit alongside these Clinical Leads on the board.
The Clinical Chairman and CEO lead the hospital, whilst the executive board takes responsibility for patient experience, clinical outcomes, staff satisfaction and finance. To measure performance against these four benchmarks we use a ‘Quality Quartet’ dashboard. This is tailored to each Clinical Unit and visible to all staff within that unit.
Our dispersed and mandated clinical leadership teams, with clinicians joined at the hip with management, are responsible for all aspects of safety, quality and finance within the organisation. Increasingly, Clinical Commissioning Boards are structured in a similar fashion with a CFO, COO led by a GP as the Chair or CEO and multiple clinicians representing the LCGs.
We believe that mandated clinical leadership is a crucial component to deliver the recommendations within the Francis enquiry. In order to achieve these changes hospitals must be receptive to this structure to remove the obstacles in the way of transformational change.
Looking further afield to the highest performing healthcare organisations, including Kaiser Permenante and the Mayo Clinic, and national organisations, including UCLH, it is clear that clinical leaders have a significant presence at each. These clinical leads make up a minimum of a quarter of the leadership teams at each of these leading healthcare organisations.
Going forward, it will be interesting to note the percentage of doctors as a proportion of FT Boards of Governors, Trust Boards and Executive Boards. The question remains, in comparison to the clinician-led CCGs have these organisational structures forced the exclusion of doctors from leadership teams? The bigger question is why the need for dispersed and mandated clinical leadership did not feature in the Francis report?
