David Nicholson, NHS Chief Executive, has set out a new and different NHS Operating Framework (NHSOF) for 2009/10 (DH, 2008). Not only is there a high-level description of what the NHS must do, but for the first time, a more explicit way of achieving it, in other words, how to do it. To succeed, hospitals must embrace the opportunities and challenges within the NHSOF, and the Medical Director will play a pivotal role.
The issue at the heart of the NHSOF is ‘quality’. Many attempts have been made, by academics and practitioners alike, to define what is meant by ‘quality’. All can essentially be summed up as organisations trying to:
“…improve their business performance, measure themselves against world class standards and focus their efforts on the customer…[and] find, record and report possible causes of error and recommend corrective action” (Oakland 1999).
In other words, organisations must understand what is required for excellent performance and have the ability to share this information with others. Overall, the goal is delivery of customer satisfaction and market success.
For the NHS, quality is defined as having 3 essential components:
· Effectiveness – are we improving health and well-being?
· Safety – are we avoiding harm?
· Patient experience – what’s it like to be an NHS patient?
The first role of the Medical Director is to ensure that quality is at the heart of the Trust’s strategy.
The implementation agenda
The NHS is a huge, public sector organisation with complex, ingrained cultures (Harrison, 1988). No matter how exciting the future agenda set out in the NHSOF, no matter how well thought through the strategy and no matter how much time and money is spent on advice, if ideas are not translated into action then the whole activity is futile. In short, good implementation is the key to success.
Within the Trust, there are various groups who have a legitimate interest in, or an expectation of, the organisation. The Medical Director must develop stakeholder management capacity, namely, a process of communication with stakeholders to understand their views, explicitly negotiate and seek agreement with them. Some groups traditionally have more power and influence than others. The Consultant body is one such group. Similarly, other clinician groups should be identified and strengthened where relatively weak. Empowered nurses, midwives and allied health professionals can be a formidable force for change when aligned with Trust objectives.
All models of quality stress the importance of leadership. A recurring theme of past failures within the NHS is the inability to effectively engage with clinicians, especially doctors, and affect their behaviours. The Medical Director functions as a ‘bridge’ between various stakeholders, in particular the Board and the Consultants. S/he must ‘…set a direction, align people to the direction and motivate them along the way’ (Kotter, 1998).
The extent to which Medical Directors matter is largely a function of the power and authority at their discretion and the way in which they choose to exercise it. For me, I consider it desirable to be bold, have high personal integrity and to present opportunities to other talented clinicians. This is especially important for those who could be identified as innovators, ‘champions’ or early adopters, and who may not yet have a recognised leadership role. Developing leadership capacity and capability is essential and I would promote internal and external development activities:
“[Leadership] commitment must be obsessional, not lip service”, (Oakland, 1999).
Fortunately, there now appears to be within the NHS, the political will, time, money and effort to foster clinical leadership at the highest levels. The medical director must encourage the Board to promote organisational development.
Knowledge is organised information. The Board needs to understand what is happening at the ‘frontline’ of healthcare within the Trust, and the Medical Director should be able to provide the clinical information relating to the hospital’s activity in a meaningful way.
The medical director should enable the Board to appreciate the factors that will determine the success of the Trust, i.e. what things must we do well to ensure success; the Critical Success Factors (CSF’s). Each CSF should be measurable and have an associated indicator of how well it is being performed; a Key Performance Indicator (KPI). (The crucial thing here is to make sure that what is important is measured, rather than make the measurable important – a common mistake!). KPI’s can be grouped into a see-at-a-glance graphic known as a Clinical Dashboard. This presents up-to-date information on a range of KPI’s, such as patient experience, infection rates, adherence to best practice, etc. Other metrics may include quality accounts, risk registers and regulator assessments.
The way we ‘do business’ in the NHS could be transformed by the impact of electronic solutions. Transformation generally means a ‘step change’ in productivity by doing more in less time and simultaneously reducing costs. Transformation will not be achieved by the traditional strategies of the past, which, if they have succeeded, have produced only incremental change. Transformation involves radical approaches and innovation. This is the goal of information-enabled service transformation. The Board should fully engage with the vision of NHS CFH and the recent health informatics review (DH, 2008). Expertise in informatics, based on clinical engagement, will ensure that the Trust achieves the strongest self-assessment of IT capability and capacity.
Appraisal, job-planning and clinical productivity
Appraisal and job-planning are an essential part of professional registration. They have traditionally been seen as ‘box ticking’ exercises by many doctors. This is because there is rarely any link between the individual’s performance and organisational objectives. The medical director must ensure that appraisal and job-planning are used to stretch individuals and groups to meet Trust objectives, e.g. by annualising productivity targets. Accurate information is essential here to compare individual doctors’ activity.
The use of sensible incentives should also be explored and encouraged, as linking performance to reward can have remarkable results. Taken together, this will produce the necessary alignment of personal and organisational objectives, frequently missing from NHS work.
The Trust Board must feel confidence in the leadership offered by the Medical Director and be persuaded by the evidence s/he provides. S/he must provide visionary and bold leadership that links to regional, national and international priorities. The medical director needs to work hard for the Trust to ensure the clinical and financial success of the hospital.
1. DH/NHS Finance, Performance and Operations (2008). The NHS in England: The operating framework for 2009/10, available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091445 [accessed 28th March 2009]
2. Harrison, S. (1988). Managing the NHS; shifting the frontier? London, Chapman & Hall.
3. Kotter, J.P. (1998). John P. Kotter on what leaders really do. Boston, Harvard Business School Press
4. Oakland, J.S. (1999). Total Organizational Excellence: Achieving world-class performance. Oxford, Butterworth-Heinemann.
5. DH. (2008). Informatics Planning 2009/10, available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091437 [Accessed 30th March 2009]