Improve your management skills, improve your clinical service

Summary

This article sets out an approach to service improvement and development that depends on psychiatrists acquiring management skills, working with managers and selecting, understanding and using some structured business tools. These are essential elements in the development of clinical leadership and service vision and can add enormously to the improvement of patient care and treatment outcomes. It is important for psychiatrists to begin to acquire these skills during their training and to continue to develop them throughout their careers.

Beyond care for individual patients and leading the multidisciplinary team, an important area of activity for all psychiatrists is developing and improving clinical services for the wider, longterm benefit of their patient population. This encompasses a range of possible activities, such as incremental improvements to services, effected through day-to-day clinical leadership and piecemeal clinical governance. It also includes occasional opportunities for wider service redesign, to meet changing service demands and expectations and, importantly, the seminal work of planning major service developments, both expansions and entirely new service provision.

There can be no doubt about the importance of the clinical contribution to service planning, development and improvement to attain the most satisfactory outcomes for patients. These are not matters that should be left to hardpressed healthcare general managers in isolation, unaided by clinical input. Evidence for this view of healthcare can be found in many studies. For example, successful, high-quality healthcare organisations focus on the detailed planning of services, based on shared clinical knowledge (Bohmer 2011), and tend to be led by a physician rather than a professional manager (Goodall 2011).

This article provides an overview of phases of service development, offering relevant elements of management theory with applicability to clinical services. The importance of leadership and management skills in training in psychiatry has been highlighted in this journal (Garg 2011; Brown 2012). The specific management competencies expected of trainees include, for example, understanding the principles of change management (Royal College of Psychiatrists 2010). Continuing professional development increasingly offers psychiatrists opportunities to learn skills such as contributing to business plans, leading a service improvement project and systematic appraisal of organisational environments (NHS Institute for Innovation and Improvement 2010) – these skills are discussed below.

This article does not attempt a scholarly discussion of management theory, but rather offers practical approaches that can be applied by busy clinical psychiatrists to the development of clinical services. It may be that the particular examples given here are useful templates, but more likely they may help readers to see the strategic, longterm value of clinicians adopting structured approaches to service challenges and of developing healthcare business skills with wide applicability.

Analysis

It is important for psychiatrists to be eager to contribute to service planning and development by offering their clinical opinion based on experience, but also on harder evidence. The clinician may be the best versed in the team (or have the most appropriate skills to access relevant information) on published national and international evidence, research on ‘what works’ in particular service fields and knowledge of emerging service models elsewhere. Clinicians' influence, impact and reputation will be further boosted if they are able to link this to systematic information about local and national comparator services – from sources such as clinical audit, diagnostic profiles, patient satisfaction and outcomes data, untoward incidents, bed occupancy, lengths of stay, waiting lists and so forth. This is an important perspective for the management team planning change; to guide areas of service development, gain a real sense of the patient's experience and needs and of the effectiveness of current service provision in the context of other services. Conversely, clinical input is also key in deciding when an area of development is not worth pursuing and can highlight a number of pitfalls of which others may be unaware.

Clinicians who can use data in a prompt, pithy and insightful way to make the case for change can add huge value to patients' experience of care. Such input by capable, business-like health professionals can be similar to that of trained business analysts in other sectors and is something that psychiatrists, among others, often do instinctively. The impact of this work can be greatly aided by the use of a few of the wide range of simple, structured business analysis techniques available. In some instances, more elaborate forms of service appraisal may be appropriate (see Assessing the effectiveness of services, below), especially where the need for change is not appreciated by others, the essence of what needs to change is less obvious and/or the change process is complex, involving multifaceted organisations and services.

SWOT analysis

SWOT analysis (strengths, weaknesses, opportunities, threats) is a simple, long-standing, widely used strategic business planning tool. It can be applied to analyse the internal strengths and weaknesses of a clinical service and to identify potential external opportunities and threats that the service faces. Examples of such external factors in a mental healthcare setting include opportunities to offer new services, changing national policies and guidelines and the threat of reducing financial resources. The value of a SWOT analysis as a business tool is to forge a clear, agreed overview of where a service is and guide the direction of change for the future. Table 1 gives a simple example of a SWOT analysis table for a rehabilitation service.

TABLE 1 SWOT analysis of a rehabilitation service

PESTEL

PESTEL (political, economic, social, technological, environmental, legal) is another tool that is commonly used in healthcare to assess how factors in the external environment may influence the organisation. The headings can be used to structure an examination of the relevant factors and how they may be addressed in any planned service development. For example, relevant external factors in developing a new in-patient unit may include a national policy to provide age-appropriate or gender-sensitive services (political), consideration of reduced financial resources from government (economic), an aging population (social) and an awareness of Deprivation of Liberty Safeguards (legal).

The capability staircase

Another useful analysis tool is the capability staircase, which assesses the service or organisational capabilities required to deliver a desired outcome and highlights the necessary sequence of steps to achieve these. It works on the basis that fundamentals need to be in place first and can then be built upon to work towards the goal. In the example shown in Fig. 1, the aim of achieving gold standard audits in a service is underpinned by adequate resources being allocated to audit activity to allow progress towards interventions for service change. This analysis of needs leads to an action plan, as shown in Table 2.

FIG 1 Analysis of needs for undertaking audits in a service using a capability staircase.

TABLE 2 Actions resulting from the needs identified in the capability staircase

This audit analysis is a fairly straightforward one that a trainee or new consultant could undertake and put into action in their own service. However, the same model can be employed for wider service improvements, moving quickly from analysis to key actions. For example, step one in the capability staircase of a service improvement may be excellent leadership to gain team agreement of the goal of excellence. The actions resulting from this identified need would be the recruitment, training and development of key service leaders. The second step may be the ability to benchmark the service against national standards, with the need being to source and train a clinical audit team. The third need identified might be change management capability with a resultant requirement for planning a communication programme for behavioural change. The final step would be the operational capability to implement the service improvement, requiring ongoing review to maintain excellence.

Vision

At all of the above stages of analysis and resulting actions, clinical leaders have a role in projecting ‘vision’. Vision is a concept that may not be natural to all healthcare professionals, but should be regarded as an important ‘strategic business tool’ with great value for any organisation or service seeking to improve and develop. Vision in this sense is essentially a vivid and inspiring articulation of how good a service could be, delivered in formal and informal settings with some frequency. A successful leader will powerfully communicate the direction of change and motivate their team at every stage to work passionately towards an inspiring vision of the future. These key skills for psychiatrists of leadership and teamwork will be discussed in a related article in the next issue of Advances (Jenkinson 2013). Creatively deploying vision, a clinical leader often plays the crucial role in persuading key players of the need to improve from the outset and then sustains the momentum of change by developing and filling out the vision through all the stages of analysis, planning and delivery. As this projection of the future grows, it enables the wider team to understand their emerging roles and take ownership of the process and prepares them to contribute effectively. Vision is a key element of change management, which is discussed below.

Business cases and project management

Following on logically from the business skills of analysis and vision is the preparation of a written business case or other formal proposal. This is key in a decision-making process appropriate for major change, involving a whole project or programme with many likely action points. A business case specifies in a clear and concise way the goals of the proposed development, the benefits in terms of patient needs and service quality, the financial plans (in terms of costs or savings) and timescales (see Box 1). A business case will typically follow the discipline of comparing the risks and benefits of two or more options, including no change, a recommended proposal and often a less favoured option, with, say, broadly similar benefits but a different financial or risk profile.

BOX 1 Structure for a business case

Business cases are decision-making tools and their format can be adapted to suit the circumstances. Common headings are:

1. • Strategic context

2. • Vision

3. • Justification for the service

4. • Cost-benefit analysis

5. • Risk analysis

6. • Resources required

7. • Financial plan

8. • Proposed schedule

Once a formal organisational decision to proceed with the service development has been made at the appropriate board or management level, an updated business case is then fed into the early implementation phase. In modern organisations, including healthcare providers, new developments are often led or supported by those thoroughly trained in business skills such as project management. These will usually involve highly structured approaches, beginning with the development of a project initiation document (PID) or similar, which in formal style sets out all of the information necessary to plan, start and manage the project and communicate with key stakeholders.

It is useful to consider four document headings: What? Why? Who? How and when?

What?

This section should explain what the service model is seeking to achieve. It should include:

1. • Background

2. • Purpose

   1. • Why is the project being undertaken?

   2. • What is the desired result?

3. • Objectives

   1. • What specific outcomes will be achieved and how will they be measured?

4. • Scope

   1. • Define the boundaries of the project

   2. • Be explicit about related areas that are excluded from the remit

5. • Constraints

   1. • What will influence the schedule (e.g. resources, external pressures)?

6. • Assumptions

7. • Deliverables

   1. • What will the output be (e.g. new ward or service)?

Why?

This section will contain the updated business case and explain the decision to proceed.

Who?

This section should outline the required project team members and their roles and responsibilities. It is important to be clear about reporting structures and who will monitor the progress and outcomes of the project. There is usually a project sponsor who has ultimate authority and control over the project and its implementation; this may be a member of the trust board. Day-to-day running of the project and coordination of the team will lie with a project manager, who could be a clinician in the service in which the project is running.

How and when?

This section will provide an initial project plan, which may be supported by more detailed project planning documents later in the process. It will divide the project into major tasks (with milestones) and provide a schedule of when these will be achieved (this can be done using a Gantt chart, as described below).

Project initiation is logically only the first step in a successful service development project. Ongoing project management is essential and allows a thorough, effective, focused approach. Clinicians should seek the support of trained individuals within their organisation. It is routine to adopt a coherent suite of project concepts and tools under one contemporary branded methodology, such as PRINCE2 (www.prince2.com/what-is-prince2.asp), which breaks the project down in a highly systematic way into steps towards desired goals, using planned resources in a proactive way.

Project management techniques can be adapted and structured to suit any clinical service development, small or large. How effectively the development is implemented will depend in large part on the depth of the project management processes and skills deployed. Clinicians who are involved in project management often see the parallels with properly planned care and treatment programmes and appreciate the benefits to patients of moving beyond an ad hoc approach to implementing change.

One universal project management tool for planning and reviewing more complex projects and change programmes is the Gantt chart (Fig. 2). This provides a shared visual basis for scheduling tasks, allocating resources and monitoring progress against the agreed programme. These charts can be created, shared and developed in a controlled way using software such as Microsoft Project. Constructing a Gantt chart requires consideration of sequential and parallel tasks and an estimation of timescales. Sequential tasks are those that need to be completed in a set order. Working this out is the essential discipline of ‘critical path analysis’, which is easy to understand in theory but difficult to follow in a complex environment. A simple example is completing the brick walls of a clinic before starting to plaster them; another is appointing and training staff before taking on patients for treatment. Parallel tasks are not dependent on each other and so can be done simultaneously, often within a wider time frame. Creating a schedule from this information about project tasks and representing it clearly in a Gantt chart is essential for efficient project delivery. Errors will lead to major cost and time overruns and to serious quality failures in new services that clinicians would wish to avoid.

FIG 2 Simplified Gantt chart for construction of a new unit (reproduced with permission of William Wake House).

Making change happen

All the stages of project analysis and delivery require both a structured business approach and a wider human element of change management to ensure that the service development is implemented successfully. To instigate innovations, one has to be opportunistic and pragmatic, as well as being aware of the change processes outlined below. It is helpful to consider a parallel with clinical work, where before behavioural change can occur there must be motivation to change. There are many theories about how to implement changes in organisations, some emanating from visionary management gurus such as John Kotter at Harvard Business School, who outlined eight stages of change management in his book Leading Change (Kotter 1996; Box 2). He examined success stories from companies which had achieved transformation and noticed two important patterns:

BOX 2 Kotter's eight steps of change management

1. 1 Create a sense of urgency

   Give colleagues dynamic and convincing reasons regarding the need for change.

2. 2 Develop a guiding coalition

   Strong leadership and visible support from key people in the organisation are crucial

3. 3 Develop a vision for change

   Articulate a clear, concise vision of why change is necessary and what you want to achieve

4. 4 Communicate the vision

   Try to embed the vision in everything within the organisation and talk about it at every opportunity

5. 5 Remove obstacles

   Consider organisational structures to ensure that they are compatible with the vision and reward people for making change happen

6. 6 Generate short-term wins

   Identify a short-term goal that you are confident can be achieved so that its success can be used as a motivator for future success

7. 7 Build on the change

   Set goals to continue building on the momentum achieved

8. 8 Anchor the changes in the organisational culture

   Continually ensure that the change is seen in every aspect of the organisation

   (Adapted from Kotter 1996)

1. • useful change tends to be associated with a multistep process that creates power and motivation sufficient to overwhelm all sources of inertia; and

2. • the change process is driven by high-quality leadership, not just excellent management.

He suggests that for any change to be successful, the majority of the management team needs to be on board, so significant time and energy needs to be spent on this first step before moving on to the next. The role of vision in achieving the key elements of change management is touched on above. Making change happen is easier for those leading it if they have real focus on the solutions to individual resistance to the change within the community involved. Effective management of this personal dimension of change can be helped by using a stepped business tool that breaks the task down, such as the ADKAR (awareness, desire, knowledge, ability, reinforcement) model (Box 3; Hiatt 2006). Such approaches help the project team extend their input effectively into the people and communication arena, achieving crucial buyin and adoption of the new developments and the changed way of operating.

BOX 3 ADKAR – target elements of achieving individual buy-in for change

1. • Awareness – of the need to change

2. • Desire – to participate and support the change

3. • Knowledge – of how to change (and what the change looks like)

4. • Ability – to implement the change on a day-to-day basis

5. • Reinforcement – to keep the change in place

(Hiatt 2006)

Managing performance and resources

A clinical leader will have shared responsibility for the delivery of a quality and volume of care, deploying a finite staff team. The skill of maximising the performance of a team depends on a mixture of inspiration and perspiration – the latter being the hard work of setting of clear, measurable, individual goals, regular review and feedback, with healthy praise and courageous challenge. Psychiatrists have the advantage of significant interpersonal and supervision skills – but these require some adaptation. An essential element is to recognise overperformance (worthy, say, of entry for national recognition and awards) and underperformance (requiring formal management and human resources measures to protect the integrity of the clinical service for patients).

The resources available in healthcare are finite, especially in the current economic conditions, and clinicians make a valuable contribution to managing these effectively. By giving care more efficiently and effectively, money is freed up for developing new services. Clinicians are increasingly responsible for managing budgets and maximising income (e.g. by increasing the number of patients treated). In mental health services especially, staffing is the major cost, so clinicians must appreciate at an early career stage the importance of managing staff effectively. It is crucial to selectively use expensive professional staff only for more complex and skilled activities and the delegation of large volumes of more routine work can be made to the wider staff group. Senior clinicians play a central role in the recruitment, motivation, training and deployment of clinical staff and can create great value for patients and organisations in seeing and implementing innovative ways to deliver excellent care with limited resources.

Assessing the effectiveness of services

Individual service improvements and major service developments overlap with the need for occasional major reviews of organisation- or service-wide effectiveness. One approach among many that clinical and medical directors can deploy is the McKinsey 7S model of organisational effectiveness (Waterman 1980). This sets out seven internal aspects of an organisation that need to be aligned if it is to be successful. It can be used to analyse where services are in terms of the seven elements and assess the intended future state for those elements. The seven factors (shared values, skills, strategy, structure, systems, style and staff) are interdependent, with change in one aspect affecting all the others. Shared values are called superordinate goals and are the core values of the organisation or service. These are critical to all the other elements. The seven elements are mutually reinforcing and essential for an organisation to function well. In relation to change management, the model can be used to ensure that wider implications are considered when a change is to be implemented in one area.

Selecting business tools

A wide variety of business tools are easily available to help any professional tackle career, strategic, management and business challenges in almost any context. A popular sources is the Mind Tools website (www.mindtools.com). Among many other things, it offers a checklist of questions using the McKinsey 7S model headings, which help to assess an organisation or service, analysing the current situation against the advantages of the proposed situation after implementation of a service development (Mind Tools 2012).

Psychiatrists, with their strong educational background and appreciation of social complexity in organisations, are as strongly placed as anyone to judge the suitability of a structured business tool to a particular challenge. It is always worthwhile pausing to consult and read widely about the use and limitations of particular tools and approaches. In the long term, however, there is no substitute for adopting a structured approach to service improvement and for learning from experience how to make this happen effectively.

Conclusions

A structured, effective approach to improving and developing services requires the use of business tools and skills. Psychiatrists should be encouraged to explore and develop these, valuing the contribution they can make to better patient outcomes. There are vital roles for clinicians both in service development and in avoiding misguided allocation of finances in areas that are not likely to improve patient care. The relatively straightforward tools described above can be used in a variety of circumstances by psychiatrists of all seniorities and in all job roles. When these skills are used in combination with clinical expertise they can help to ensure that psychiatrists are leading innovative and effective services.

MCQs

Select the single best option for each question stem

1. 1 How many stages of change management did Kotter outline?

   1. a five

   2. b six

   3. c seven

   4. d eight

   5. e nine.

2. 2 In the ADKAR model, the R stands for:

   1. a recovery

   2. b reinforcement

   3. c repetition

   4. d removal

   5. e reinvention.

3. 3 Which of the following does not appear in the McKinsey 7S model?

   1. a structure

   2. b strategy

   3. c service

   4. d style

   5. e skills.

4. 4 The capability staircase is:

   1. a a change management tool

   2. b a type of project initiation document (PID)

   3. c used to articulate vision

   4. d an analysis tool

   5. e similar to a Gantt chart.

5. 5 A Gantt chart:

   1. a can be used instead of a PID

   2. b lists only sequential tasks

   3. c can be created in Microsoft Access

   4. d is produced before the business case

   5. e is a project management tool.

MCQ answers

1 d

2 b

3 c

4 d

5 e