Nederlandse Tropen Cursus NTC & Core Course MIH

Daily management and training

Daily managementof a health facility

Pieter van den Hombergh

IQhealthcareWorking party On Q of Care Research

LHV Dutch Association of GPs

Program Wednesday 12-5-2010

Morning9.00 - 10.00 Introduction 10.00 - 11.00 Analysis of Kilgoris, a LIC health facility

Coffee11.00 –12.00 Practicing management skills

Lunch13.00 – 13.30 Making plans13.30 – 14.00 ABC-drill 14.00 – 15.00 Practicing ABC15.00 – 15.30 Evaluation & Final slides

Management of the organisation is quality of care

patientPhysician A

Matron

Surgeon B

Nurse A Midwife B Tutor

Organizing your work =

fun

&

magic

What is management?

To enable people

to perform jointly

creating the required conditions

Conditions:- Joint goals and values,- Training and guidelines- Structure- Leadership: Pusher, Puller, Player, Pleaser

The professional

• Shows creative and independant thinking

• Has experience, craftmanship & knowledge

• Sticks to professional values and guidelines

But is a hopelessly unguided missile.

QUALITY IMPROVEMENT Why practice management?

Improvement of practice management

=80%

of all possible improvement in health care

Management Field descriptionMain categories in a health facility

I Infrastructure

II Team

III Communication

IV Finance

V Quality of care/Safety

Premises, equipmentService, AccessibilityDoctor’s bag, First AidDelegation, job mix Workload, JobstressPatiënt records, staffNetwork of care givers, ICTYear-report

Certification, InnovationQI, protocols etc.

Organisation Analysis

T h e m os t b a sic an a lys is

O u tp u t

H o sp ita l

In pu t

Organisation Analysis

Donabedian

O u tco m e

P roce ss

S tru c tu re

Organisation analysis

Urgency

Cohesion

&

Urgency

Choose from your heart

=

The fuel for performanceElastic band

What I want? Reality Creativity Stress

Urgency

Negative if:• Goal is sky high• Goal is not realistic • Time is short • Urgency depends on

someone else (boss)

Negative urgency causes stress, is tiresome

Positive if:• Goal is tickling• Goal is realistic • Well planned in time• Is well perceived by you,

comes from your heart

Positive urgency is inspiring, creative & gives energy

Different organisations

Bureaucratic

• Formal, values + guidelines

• Supervision by superiors

• Standardisation of tasks

• Authority based on social order

• Fit for e.g. passport

Professional

• Autonomous, creative

• Supervision by colleagues

• Standardisation is a problem

• based on knowledge and skills

• Fit for advertisement bureau

Model of MintzbergStructure

=

the way

the organisation

has divided work in tasks

and

the way

it coordinates these tasks.

Professional organisation

• Professional burocracy

• Too many professionals

• Too little support

• Difficulty in standardisation

• Small top

Without MISSION & VISION

is

each question, each daily problem, each situation

a confrontation

with the lack of

common purpose

Setting goals / objectives

The importance

of an

explicit, clear and transparant

GOAL

Importance of setting goals

• Powerful management-instrument

• Noses in the same direction

• Clarifies the problems

• Can be evaluated

• Can be split in parts

• Is communicable

• Motivates

SMART Objectives

S pecific

M easurable

A chievable - Aantoonbaar

R elevant

T ime-limited- Tijdgebonden

CARE What is optimal?

optimum

Patient

demand

Doctors, Hospitals, Local healers

Supply

DemandTrue needs

Tb

Smoking

AIDS

Blindness

Reflection TransparancyAccountability Reward

Clinical effectiveness

From goal to strategy

GOAL STRATEGY

SWOT-ANALYSIS

THE ENVIRONMENT

data

year-report

policy- advice

Threats & opportunities analysis

Health

facility

HospitalCommunity

Church

Colleagues

Referral hospital

Dispensaries

District health authority

Drugs supply

Training centre

Demographic, political & economic developments

Social, technological & communication developments

MANAGEMENT SKILLS

• To motivate

• To analyse

• To communicate

• To delegate

• To negotiate

= To direct, guide

= To think, make an inventory

= To inform

= To plan

= To use power

IN THE PURSUIT OF QUALITY OF CARE

every defect

is

a treasure

Ability to manage versuswillingness to manage

High

Willingness

to

manage

Low

Danger

manager

Super-

manager

Incompetent

meddler

Opt-out

Ostrich

Low High

Ability to manage

Ability to manage versuswillingness to manage

High

Willingness

to

manage

Low

Danger managerPush ideas despite few skills Introduce inadequate systems

Leave a trail of confusion

Super managerEvangelical gleam in eye

Passion for change

One such GP is enough

Incompetent meddlerHates planning

Fails to complete vital records

& to communicate with staff

Change their mind for no reason

Insist on being consulted

Opt-out ostrichUnfortunate, could be very useful

Tolerates some chaos

Delegates smart

Loves to be GP

Low High

Ability to manage

Long term planning versuspractical daily management

good in good

practical

Daily

Management . bad

myopic visionary

Bumbler stumbler

Bad Good

in long term planning

Long term planning versuspractical daily management

good in good

practical

daily

management . bad

Myopic

Stagnates

Visionary

Winner

Bumbler

Out of touch

Stumbler

Unpractical

Bad Good

in long term planning

Long term planning versuspractical daily management

good in good

practical

daily

management . bad

Myopic

Stagnates

Visionary

Winner

Bumbler

Out of touch

Stumbler

Unpractical

Bad Good

in long term planning

Managing =

• Choose

• Commit yourself

• Be reliable, trustworthy, true to yourself consistent, not letting people down.

• Know your strengths and weaknesses

This how you show

integrity and respect for yourself!

Managing = not manipulating

• Think in win – win (not I win you loose)

• Don’t give up on integrity

• Check intentions and consult your conscience

• A goal never justifies the means

• Only want, what can be done

Good Clinical Governance

=

Sum of

Quality Improvement

&

Accountibility

MANAGEMENT SKILLS

• Analyse = Thinking in problems

openness

MANAGEMENT SKILLS

• Analyse

• Communicate

= Thinking in problems

=

OPEN COMMUNICATION

• Systematic approach in the consultation

• Don’t think in solutions, avoid jumping to

• Listen open, don’t judge

• Try to get the whole picture first

• Encourage with ‘hmm’, ‘o yes’

• Check

MANAGEMENT SKILLS

• Analyse

• Communicate

• Motivate

• Delegate

= Leadership

= Plan

Motivating people

People do not get tired of

working hard,

but they do get tired of

lack of purpose and lack of power.

TO MOTIVATE

Motivating elements

• Their own tasks with

• Responsibility

• Time for consultation

• Consultation at an early stage

• Passing on knowledge and skills

• Appreciation and positive feedback

TO DEMOTIVATE

Demotivating elements

• Working place is awful or not available

• Too little responsibility

• Too litle time for consultation

• Vague tasks & agreements

• Starting late

• Finishing late

TO DELEGATE

CONDITIONS FOR PROPER DELEGATION• Motivation of the staff• Competence of the staff• Supervision• Presence of the supervisor• Space for the delegated tasks• Informed consent of the patient

TO DELEGATE

ACCEPTANCE BY THE PATIENT

Better acceptance, when

• staff is licensed

• staff is supervised

• staff has experience

• staff does other tasks as well

• Staff has autonomy and professional charter

GIVING FEEDBACK

• Start with the good things

• Be factual, descriptive

• Be specific

• Discuss behaviour that can be changed

• Offer alternatives

• Be owner of the feedback

• Feedback discloses your motives

RECEIVING FEEDBACK

• Listen first, don’t reject, don’t argue, let it sink in

• Ask for clarification, when necessary

• Check the feedback with others

• Ask for the feedback you want

• Determine beforehand what you want to do with the feedback

MANAGEMENT SKILLS

• Analyse

• Communicate

• Motivate

• Delegate

• Organise= prepare

= CheckEvaluate

MANAGEMENT SKILLS

• Analyse

• Communicate

• Motivate

• Delegate

• Organise

THE MANAGEMENT CIRCLESetting goals

Observe AnalyseThink

Ask Plan

Evaluate Organize

ImplementCoordinate, motivate

PLANTREATMENT cq ADMISSION ROOM

Problems • Insufficient light • Parents fill the room• Admission room gives also access to treatment room • Nurses are always present doing other tasks • Concentration of staff sucks patients; That was where it happened. • At the end of a day people are more grumpy. • Treatment room too small in times of Malaria/meningitis• Admission room too small with too many purposes. Advantages• "Relatives" were in treatment room behind the "slab", with child• Staff kept an eye on seriously ill children during admissioon• Equipment present during admission for treatment (LP, IV, O2)• The treatment room had sufficient light

PLAN

Doing the

right things

right

Doing the

right things PLAN

CENTRAL QUESTION

FOR EACH PLAN

What does it solve?

PLAN

Doing the

right things

right

Doing the

right things PLAN

Strategic Operational

Effectivity Efficiency

PLAN

Doing the

right things

right

Doing the

right things act

Strategic Operational

Effectivity Efficiency

observeanalyse

choose

design plan

do

check

Remember the Deming circle

ABC-drill

• A explains to B his objectives (goal, problem, plan). He does that systematically, giving A a brief outline of his practice profile

• B listens actively and communicates openly

• C is in charge of the process and the time (15 min) and makes notes. 5 Minutes before time C askes A and B to report on the process and C gives feedback

A

• A tells B what A’s vision is of the future practice and how that fits into A’s personal life plan.

• What are A’s objectives formuled SMART, clear and open to B .

• A informs B systematically. • A gives a practice profile to B and C • A invites B to ask critical and explorative questions• Don’t discuss, you waste time • A asks B for an honest opinion

B = McKinsey

• B communicates open, without judgement• B tries to get a finger behind A’s problem • B doesn’t give advice, doesn’t solve A’s problems • Use helpful questions:

– What does A want to realise in the short/long term?– Why does A have that vision, What are A’s intentions?– For who, with whom does A want it?– What does A’s plan solve?– What is A’s problem?– How do I see A’s problem?

C

• C listens, makes notes, corrects A and B• C checks the time and is chairman• C guards the process• C gives feedback in the last 5 minutes• C askes A and B to report on their perceptions

– Feedback is factual, specific, clear– Tell what you saw and heard without judgement– Check your feedback. Was it correct?

CHECK your plan

• Is it a reaction to something? (beside your heart)

• What does it solve, contribute?

• How well does it fit in?

• Is the plan conditional? (the plan works if .... )

• What/who has to cooperate to make it a success?

• What are the consequences?

CRITERIA FOR A GOOD PLAN• Objectives clearly indicated?• Goal and policy transparant?• Based on a thorough analysis?• Was the literature consulted?• Consistent?• Realistic?• Plan is stimulating or rather frustating?• Money and means are explicitly mentioned?• Tasks and responsibilities explicit?• Delegation gets enough attention?• Clear priority of steps?• Does the plan give enough direction?

LEARNING POINTS

• Write them down• retrievable• to the point• factual, concrete• specific• detailed• exchange them in the group and • colleagues at home

MANAGEMENT of

CHANGE

An ultimate abstraction

MANAGEMENT of CHANGE

• Every change has both a technical and social

aspect

• Technically rational changes can fail if the

social aspects of change are not handled well

• Every system is perfectly designed to get the

results its gets

MANAGEMENT of CHANGE Deliberate leadership

• Goal setting

• Communicating

• Coaching

• Role modeling

• Support building

• Barrier removal, facilitation

MANAGEMENT of CHANGE VISION for office practices

Encounter level principles

1. Paramount focus on the clinician-patient relationship

2. Individual access to care and information at all times

3. Knowledge based medical care as the standard

4. Individuals control and customize their own care to the extent that each individual desires

5. Minimal waiting for all involved in the care process

6. Seamless communication of information & coor-dination of care based on collaborative relationships

MANAGEMENT of CHANGE VISION for office practices

System-level principles1. Financial management sufficient to ensure

unhindered viability2. Patient, population and practice management based

on real-time process, satisfaction finance, outcome, and epidemiological data

3. Individual health linked to broader community health perspective

4. Continual improvement and waste reduction in all processes and services

5. A model working environment

MANAGEMENT of CHANGEAims for improvement

• Clear, specific, measurable terms

• Consider ‘stretch’goals, but be prepared

• Constancy of purpose matters

• Focus, not everything at once

MANAGEMENT of CHANGEStaff involvement

• Motivation is internal to a person • Create conditions where people’s internal

motivation can flourish • Start small, but valuable• Start non threatening• Flow: time is available for things people enjoy

doing• Rewards: acknowledgement is valuable,

respond to all input• Be clear abot constraints upfront • Focus on opinion leaders

MANAGEMENT of CHANGEModel for change

Tension for change

An effective alternative

Social support Self-efficacy skills Plsek

Feedback

CHANGE

Intention to change

MANAGEMENT of CHANGE Transforming an organisation

• Establish a sense of urgency

• Form a powerful guiding coalition

• Create a vision and communicate that vision

• Empower others to act on that vision

• Plan and create short term wins

• Consolidate and produce more change

• Institutionalize new approaches

MANAGEMENT of CHANGESources for change of ideas

• Evidence in the literature

• Benchmarking and the experience of other

organizations

• Expert opinion

• Ideas based on sound theory

• Creative thinking

MANAGEMENT of CHANGEMeasurement

• Measurement for improvement instead of judgment

• Usefulness over perfection– Simple, easy data collection in daily work

– Consider sampling

– Consider existing data sources

• Timeliness of feedback is key to learning

• Long ‘baselines’ are often unnecessary

• Annotated graph of measures over time

MANAGEMENT of CHANGEWhy test?

• Increases belief that change will result in

improvement

• See how much improvement can be expected

• Adapt ideas to local context

• Evaluate cost and side-effects

• Minimize resistance; create attraction

MANAGEMENT of CHANGEModel for change

Urgency for change

An effective alternative

Social support Self-efficacy skills Plsek

Feedback

CHANGE

Intention to change

MANAGEMENT of CHANGEPlanning for change

• How will we convince ourselves and others that there

is truly a need for change? (URGENCY)

• How will we convince ourselves and others that the

new way is better? (ALTERNATIVE)

• What will we do to avoid the feeling of Ï am all alone

in making change’? (SUPPORT)

• How will we and others acquire the skils to make the

new way work? (SKILLS)