Implementation

Implementation is making something happen.  At a high-level (organisational), it means making the strategy happen; at a lower level (‘business-unit’) it means making the policies and guidelines happen.

Untrained managers often think that writing a policy is what their job is about.  Naively, they think that physically showing it to staff (or telling them where it is) will magically mean that it will be acted on.  Wrong!  Writing the policy (no matter how tedious) is the easy bit.  90% is the implementation.

Implementation involves planning, execution and control.  The public sector, the NHS in particular, has a poor record in this regard.  Partly this may reflect the culture of NHS management, which is one of overriding influence from the centre.  Personally, I suspect it is because implementation is difficult and we don’t train people to do it.  A helpful way to consider successful implementation is to think about the things that hinder it.  Here are five well-known barriers to implementation:

• Unsupportive organisational structure
• Different stakeholder requirements
• Organisational politics
• Poor understanding of process management issues
• Low status of the project team

Are they relevant in your situation?  If so, don’t ignore them, but plan how you are going to tackle them.  If this seems too daunting, consider brain-storming with a trusted colleague or two.   Maintain a sense of perspective, give feedback, and have fun – there is nothing more engaging than genuine, child-like, enthusiasm!

In later posts, I’ll talk about forming action-learning sets.

Bark worse than their bite

Some Executives are scared of clinicians, and doctors in particular, who have a reputation of being ‘difficult’.  However, you will have much more success if your change initiative ‘fits’ with medical culture. 

• Don’t hide behind General Managers. By this I mean, don’t expect relatively junior managers to do your work for you
• List benefits and risks, (just like getting informed consent for an operation!). Doctors are bright people and can understand most complex situations if you take time to explain it to them
• Be honest, especially about likely problems. Don’t spout propaganda
• Stress your personal commitment
• Provide resources for ample training
• For doctors, show where the personal financial benefits might be

This last point is often avoided.  Doctors are distinctly ‘calculative’ in their perspective.  This means, they need to know the answer to the question, ‘what’s in it for me?’  Obviously, this isn’t always direct financial reward (though it often is), but the benefits should be made explicit.

The NHS has a poor record of incentivising personnel to perform, which is bizarre as we know it works.  Notwithstanding, there are usually ways to link productivity to reward if you try.  I think it’s time that medical leaders acknowledged this and lobbied for clinicians to be allowed to reap productivity rewards within the NHS.  At present, we often push the highest performing doctors into the private sector, simply because of this public sector ‘productivity paradox’.  For instance, I could be the best anaesthetist in the NHS, or the worst, and it wouldn’t matter, I get paid the same.  Worse still, if I’m a surgeon and don’t perform very much, I will soon be offered ‘incentive lists’ (extra work at hugely enhanced rates) to do more.  Thus, I get paid more for performing poorly!  You do the maths!  Doctors aren’t daft; if they drag their feet, deliberately or not, they will earn more money.

As a famous Economist once said, “Economics can be summed in the the phrase, ‘people respond to incentives’.  All else is comment”!

Not responding

Everybody’s busy.  But, clinicians feel that they are busier than everyone else!  They are certainly too busy to attend ‘meetings’ at the drop of a hat.  For some managers, this comes as a bit of a shock.  They themselves are used to responding to urgent calls on their time and being ‘summoned’ by a superior.  Doctors, however, prioritise their time around clinical work, anything else is a distraction and nearly always a waste of time.  So, if you’re a manager, don’t be surprised when no-one turns up to a ‘clinical engagement’ meeting you’ve arranged.  This is, in fact, a favorite and extremely effective ruse that clinicians use; just ignore management requests, simply don’t engage.  It works so well because it’s passive aggression.  It doesn’t involve unpleasant confrontations or having to find rational arguments.  It is astonishing how often new initiatives fail simply because the clinicians avoid them.  (You will have noticed this phenomenon with some types of email.  If you let it sit in your inbox for a few weeks, it slowly loses relevance.  Eventually, you can delete it without having done anything!)

But, if you’re serious about clinical engagement you should:

• Go to where the clinicians are. Get in their faces! You must be seen to be believed.  Management by walking about is absolutely true.
• Ask to attend their own meetings, e.g. audit sessions, lunchtime meetings, postgraduate lectures, find out!
• Use “clinical champions”, but show you support them by your presence

A really useful technique is to arrange for other groups to be present, such as ‘lowly’ A+C staff.  If you can get the Consultant’s secretary on board, it will be much easier to get the Consultant.  Similarly, patients and patient groups can be powerful allies.  Clinicians dare not contradict them, at least not in public.  Patient stories are very disarming and can make points that would be very difficult for a manager to get across.

A lot of this stuff is just straightforward change management.  However, as we know, common sense is not common practice.

Analysis of cultural diversity in a NHS Trust using Schein’s 3 level scheme

Following on from sub-culture, I think we can see that these 3 groups within a hospital have their own distinctive identity (see what you think!).  I’ll consider some of the implications in the next post. 

Level 1 Surface manifestations

Medical: White coats, stethoscopes, ritualised ward rounds, fellowships of Royal Colleges, eminent personalities
Managerial:  “civilian” clothes, plush offices remote from patient areas, separate hierarchy
Nursing: Uniforms, “hands-on” work, largely female, local training

Level 2 Values and beliefs

Medical:  Personal contract between doctor and patient, clinical freedom, scientific basis for treatment, member of profession, not employee of Trust
Managerial: Loyalty to Trust, resources limited by centrally-controlled budgets, financial prudence, adherence to central policy
Nursing:  Patient advocacy, care more than cure, nurturing, comfort, self-sacrifice, hygiene

Level 3 Basic assumptions

Medical:  Hippocratic Oath, patient confidentiality, sanctity of life, responsibility to patient
Managerial:  Responsibility to Trust/NHS for public money expenditure, health gain of population more important than individuals
Nursing:  Primacy of the individual, patient dignity

By analysing the sub-cultures using Schein’s model, it may be possible to identify common themes within each.  Appealing to common values may allow greater acceptance of change initiatives.  Moreover, those parts of the change initiative which fit with a particular subgroup can be emphasised most for that situation.  In other words, inasmuch as the senior management is a part of the culture, they may be able shape aspects of it to suit their agenda.

I’ll give some specifics in next posts!

Sub-culture

Doctors occupy their own sub-culture within their organisations.  They are different to other clinician groups, such as nurses, and especially different to non-clinical groups.  They are also disproportionately powerful, so any change initiative must take into account their uniqueness. 

Sub-culture can be understood by Schein’s 3-layer model:

1 Surface manifestations  (artefacts, ceremonies, rituals, heroes, sagas, etc)

2 Values and Beliefs  (conscious strategies, goals and philosophies)

3 Basic assumptions  (e.g. nature of reality, truth, relationships)

Each layer interacts with the others, so a seemingly simple change, (say to implement a ‘bare below the elbows’ policy for direct patient contact), which impacts on doctors’ surface manifestations, e.g. white coat, or lounge suit for Consultants, is felt as an attack on the doctors’ basic assumptions.  Since doctors ‘assume’ the dominant role within the doctor-manager relationship, they are not about to be told what to do by ‘subordinate’ managers!

In the same way, nurses and other non-doctor groups don’t complain because they perceive the policy to ‘fit’ with their relationship with the managers (where the managers are dominant).

The proof of this is the knee-jerk reaction of doctors alone in the popular medical press (and the flurry of indignant internal emails), decrying the policy!  This reaction was entirely predictable using Schein’s model, yet seems to have caught many managers on the hop.

Managing change

“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in a new order of things.”   (Machiavelli, 1469-1527)

Being a manager or leader is nothing if not bringing about change (as opposed to administration, which I consider to be maintaining the status quo, i.e. specifically not changing).  It must be a core aspect of a manager/leader’s role and so I don’t need to rehearse the elements of managing change here, as any decent book on change management will do that.

However, what surprises me is that so often management initiatives that involve change are so often undertaken without reference to standard, obvious change management principles.  Did the managers responsible never learn this stuff at Business School?  More likely, the managers/leaders never went to business school or feel it’s somehow not relevant in the ‘real’ world.  A CEO I worked for once said to me, “Paul, you’re the only person I’ve ever met who practises what we were taught in our MBAs”.  At first, I thought it was a put-down, but on reflection I realised he was right; there is a ‘theory-practice gap’.  We know what the right thing to do is, but we find it incredibly hard to do! (Romans 7:18,19).

Clinicians find it especially difficult to lead change, not least because they’ve rarely had any training in it.  In my next few posts I’ll suggest successful techniques for leading change in a clinical context.

Homophily

This is a great word a learnt recently!  It means that sense of peer-to-peer understanding that we get when communicating with someone we don’t necessarily know, but with whom we share some common bond, e.g. professional status.  So, a doctor speaking to another doctor will always get a fair hearing on a controversial subject, whereas a manager or politician may not. 

It doesn’t mean that your peer will agree with you unthinkingly, but you will at least get a ‘foot in the door’ to make your pitch.  If you don’t have homophily with your audience, you should consider ‘buying it in’; in other words, bring someone with you who does, and let them do the talking.

Bear in mind that homophily works best the closer the bond.  Thus, a doctor-doctor bond is fine, but a GP-GP bond works better than a GP-Consultant one.

Homophily is crucial for clinical engagement with controversial subjects and sceptics!