A Mandatory Management/Leadership Development Framework for Doctors Professor Peter Spurgeon Director of Institute of Clinical Leadership University of Warwick A Mandatory Management/Leadership Development Framework for Doctors

Enhancing Engagement in Medical Leadership Joint Project undertaken by National Institute for Innovation and Improvement, and Academy of Medical Royal Colleges Overall goal ‘create a culture of greater medical engagement in management and leadership with all doctors at every level’ Two key products Medical Leadership Competency Framework Medical Engagement Scale

Project Benefits Benefits to the NHS and medical professionals include: Greater commitment and capability to effect service change and improvement Support the drive towards the new medical professionalism Greater awareness by medical professionals of the contribution of effective management and leadership in both operational and strategic activities Increase and strengthen the pool of medical managers and leaders available to take on senior roles within the service

Project Products and Research International study on preparation of doctors for leadership roles Research into the link between medical engagement and organisational performance including Literature review Interviews with Chief Executives and Medical Directors Development of a medical engagement scale Engaging doctors publication Medical Leadership Competency Framework

Medical Leadership Competency Framework Describes the leadership competences doctors need to become more actively involved in the planning, delivery and transformation of health services. The MLCF is being used to: Inform the design of training curricula and development programmes at undergraduate and postgraduate stages of a doctors training Highlight individual strengths and development areas through self assessment and structured feedback from colleagues Assist with personal development planning and career progression through to revalidation The MLCF applies to all medical students and doctors

Medical Leadership Competency Framework Tested in 5 sites across the country Sept – Dec 07 included medical schools, postgraduate deaneries, acute and primary care trusts Further amendments made and endorsed by the Steering Group and Academy of Medical Royal Colleges in March 08 Delivering services to patients and others who use healthcare services is at the heart of the Competency Framework. The five domains (Personal Qualities etc) highlight the general areas in which doctors need to be competent. Each domain is subdivided into four elements, each element is further divided into four competency outcomes. www.institute.nhs.uk/mlcf

Medical Leadership Competency Framework Development of the Medical Leadership Competency Framework (MLCF) was informed by: A review of literature and key publications Comparative analysis of leadership competency frameworks Analysis of medical curricula Consultation with members of the medical and wider NHS community including General Medical Council (GMC) Postgraduate Medical Education Training Board (PMETB) NHS Confederation NHS Employers Conference of Postgraduate Medical Education Deans (COPMeD) Medical Schools Council (MSC) British Medical Association (BMA) Input from the project steering group, reference and focus groups, test sites and AoMRC patient/lay group.

Medical Leadership Competency Framework Application of the MLCF will differ according to the career stage of the doctor and the type of role they fulfill. The following graphics demonstrate the emphasis that is likely to be given to the domains at each stage: Undergraduate Postgraduate Continuing Practice

Demonstrating Personal Qualities Doctors showing effective leadership need to draw upon their values, strengths and abilities to deliver high standards of care. Developing self awareness: being aware of their own values, principles and assumptions and by being able to learn from experiences Managing yourself: organising and managing themselves while taking account of the needs and priorities of others Continuing personal development: learning through participating in continuing professional development and from experience and feedback Acting with integrity: behaving in an open, honest and ethical manner.

Working with Others Doctors show leadership by working with others in teams and networks to deliver and improve services. Developing networks: working in partnership with patients, carers, service users and their representatives, and colleagues within and across systems to deliver and improve services Building and maintaining relationships: listening, supporting others, gaining trust and showing understanding Encouraging contribution: creating an environment where others have the opportunity to contribute Working within teams: to deliver and improve services.

Managing Services Doctors showing effective leadership are focused on the success of the organisation(s) in which they work. Planning: actively contributing to plans to achieve service goals Managing resources: knowing what resources are available and using their influence to ensure that resources are used efficiently and safely, and reflect the diversity of needs Managing people: providing direction, reviewing performance, motivating others and promoting equality and diversity Managing performance: holding themselves and others accountable for service outcomes

Improving Services Doctors showing effective leadership make a real difference to people’s health by delivering high quality services and by developing improvements to service. Ensuring patient safety: assessing and managing the risk to patients associated with service developments, balancing economic considerations with the need for patient safety Critically evaluating: being able to think analytically, conceptually and to identify where services can be improved, working individually or as part of a team Encouraging improvement and innovation: creating a climate of continuous service improvement Facilitating transformation: actively contributing to change processes that lead to improving healthcare

Setting Direction Doctors showing effective leadership contribute to the strategy and aspirations of the organisation and act in a manner consistent with its values. Identifying the contexts for change: being aware of the range of factors to be taken into account Applying knowledge and evidence: gathering information to produce an evidence-based challenge to systems and processes in order to identify opportunities for service improvements Making decisions: using their values, and the evidence, to make good decisions Evaluating Impact: measuring and evaluating outcomes, taking corrective action where necessary and by being held to account for their decisions

Undergraduate The revised Tomorrow’s Doctors released Sep 2009 includes MLCF Project support will include Update to Medical Schools Council and offer support to Medical Schools to implement MLCF Meet with Medical School Deans to assess progress and offer advice regarding implementation Development of a resource and learning pack with a consortium of medical schools Identify minimum levels of attainment across the domains to assist in development of appropriate assessment Contribute to Medical Professionalism Roadshows across the UK (with Royal College of Physicians, King’s Fund and GMC)

Postgraduate All Medical Royal Colleges and Faculties are undergoing a review of their curricula, PMETB has advised that the MLC is to be included in this revision. Project support includes: Medical Leadership Curriculum has been developed, based on the MLCF and provided to all colleges and faculties Meeting with each college to discuss approach to implementation, and how we can support this process Providing assistance to colleges and faculties regarding assessment Development of e-Learning for Healthcare (DH) material that will be available to all doctors in training, regardless of specialty, in early 2010 Supporting the delivery of the new curricula with tools and support for training clinical tutors

Continuing Practice Revalidation will be introduced from 2011 and the project team are working with the relevant regulatory bodies to ensure the MLCF is included in the guidelines Project support includes: Meeting with SHA Medical Directors and Home Country Chief Medical Officers to raise awareness and advise on implementation including delivery Contribute to review of Good Medical Practice Work with DH, NHS, GMC and AoMRC on revalidation, providing input on MLCF

Engagement is Critical to Organisational Performance Since 1997, Gallup’s extensive Q12 survey has assessed more than 4 million individuals – results revealed that of less than a third of employees (29%) are actively engaged in contributing to their employing organisations success In 2003 “The Quest for Quality in the NHS” (Leatherman and Sunderland) described UK clinicians as being attentive but not fully engaged in the NHS quality improvement agenda Successful medical engagement is crucial to future improvements in the NHS and is a policy priority with high performing NHS Trusts consistently identifying high levels of medical engagement as the key factor in achieving service improvements (Emphasised in Lord Darzi’s High Quality Care for All: NHS Next Stage Review Final Report – 2008) NHS organisations not only need reliable and valid tools to measure how well they engage doctors, they also need to promote and embrace a cultural change where managers and medical staff actively want to build better, more co-operative and productive relationships that drive service improvements

The Three Aims of the Research To develop a reliable and valid measure of medical engagement in leadership which will be quick and relatively unobtrusive to complete To differentiate within the scale a measure of personal engagement at an individual level (the motivation of the individual to perform in appropriate managerial and leadership roles) from the organisational context (which may foster or constrain engagement) To develop a systematic framework for recommending organisational strategies capable of enhancing medical engagement and performance at work

Key Assumptions of Current Approach Improvement in healthcare needs the positive involvement and engagement of doctors who are highly influential in planning and delivering service change Competence can be thought of as what someone “can do” but engagement requires a “will do” attitude Reliable and valid measurement and monitoring of medical engagement is critical since this will inform and shape the effective management of change Many definitions of engagement focus solely on individual aspect of engagement whereas the current approach also incorporates organisational conditions Our definition of Medical Engagement is:- ‘The active and positive contribution of doctors within their normal working roles to maintaining and enhancing the performance of the organisation which itself recognises this commitment in supporting and encouraging high quality care.’ [Spurgeon, Barwell & Mazelan, 2008]

Origins of the Medical Engagement Scale (MES) Applied Research Ltd. – Established large database re: attitudinal, individual & cultural aspects of NHS Existing measure of work satisfaction and personal commitment based on 23,782 NHS staff and 20+ health organisations Best items from previously established scales selected as relevant to medical engagement and re-analysed using Factor Analysis Scales adapted to focus on engagement - reliable, valid & relatively easy to administer & complete

Pilot Phase Focus Piloting took place in 4 NHS Trusts. 200-250 measures distributed, 118 medical staff returns & 19 senior managers (above 50% response rate) The pilot was aimed at developing a reliable and valid measure of medical engagement in leadership which will be quick and relatively unobtrusive to complete The measure comprised a set of items representing various scales and a behavioural checklist, enabling an assessment of the alignment between the medical and managerial perspectives To explore within the scale a measure of personal engagement at an individual level (the motivation of the individual to contribute to appropriate managerial and leadership roles) from the organisational context (which may foster or constrain engagement)

Scales and Definitions

MES Reliability & Validity Overall items reduced to 18 [or 30 for full sub-scale version] with reliability scores (Cronbach’s alpha) ranging from 0.70 to 0.93 Inter-scale correlations with key core concepts of engagement suggest - engagement is a conceptually distinct construct the sub-scales are important as engagement is multidimensional Scores from the pilot trust sites were statistically significant & in the predicted order i.e. top two are rated excellent & have taken steps to promote medical engagement, the last is in the poorest performing category & opportunistic site in the middle

MES Medical Engagement Model The MES model emphasises the interaction between the individual doctor and the organisation. The MES model emphasises the interaction between the individual doctor and the organisation.

The MES Scale Hierarchy

MES Index: Position on Model for 4 Pilot Trusts

Meta-Scales: Position on Model for 4 Pilot Trusts

The Levels of Medical Engagement

Engagement Intervention Strategies The IHI Framework for Engaging Physicians in Quality and Safety – Reinertsen et al (2007) - comprises six areas which can be used as a checklist for engaging physicians in quality and safety. In a similar way the hierarchical structure of the MES has also been linked to suggested potential intervention strategies and these are outlined in the hierarchical figure shown.

Levels of Medical Engagement Summary for Trust 1

Levels of Medical Engagement Summary for Trust 28

Levels of Medical Engagement for All Trusts in Current Sample

Contact Details Professor Peter Spurgeon Professor of Health Services Management p.c.spurgeon@warwick.ac.uk Website: www.institute.nhs.uk/medicalleadership Email: medicalleadership@institute.nhs.uk © Copyright 2008 NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges