1. Insert name of presentation on Master Slide Thursday 8 August 2013 – 4.30-5.30pm Doctors Championing Change Session 3: Creating a compact that supports you

2. Guest speaker Dr Jack Silversin International author and speaker. Co-author of Leading Physicians Through Change. Today’s session is chaired by Dr Alan Willson Director of 1000 Lives Plus

3. Today’s session format Introduction First session – Jack Silversin (20 mins) Question and Answer session (5 mins) Second session – Jack Silversin (15 mins) Question and Answer (10 mins) Final comments and close

4. Part 1 Topics What is a compact Why should I care? How could it be helpful?

5. 3.Compact: explicit expectations that support the vision 2.Effective clinical leadership; support change, not advocate for status quo 1.A organisational vision or aspiration that is shared Three Strands Essential for Engaging Doctors in Quality None alone is sufficient. All three are necessary

6. How Compact Work Helps Talk about expectations and disappointments tills the soil for true engagement Helps to align what is expected of doctors with what it is needed for organisational success Virginia Mason Medical Center, Seattle, Washington has had great success with their application of Toyota Production System (TPS) Dr. Gary Kaplan, CEO, states that clarifying expectations through compact work prior to adopting TPS greatly helped their progress

7. OVERVIEW: Doctors and Organisations Are Talking About A New Compact Compact is “shorthand” for reciprocal expectations between 2 parties – for example a hospital and the doctors working there As health care delivery rapidly changes, many organisations and their doctors find it helpful to clarify what they can expect from each other This work involves a good deal of dialogue and usually helps to build mutual understanding and trust The goal of the process is a clear and agreed to set of “rules of engagement” that support delivering health care in today’s environment

8. Compact Expectations people who work in an organisation have that are: –Unstated yet understood –Reciprocal ›What members of the organisation give or must do to fit in and meet the organisation’s expectations of them ›What members can expect from the the organisation they are a part of –A successful and sustained compact is mutually beneficially –In the case of doctors, typically compact set up by society and reinforced by the organisation

9. Compacts All hospitals and other medical organisations have compacts with doctors and other staff IMPLICIT/TACIT Or EXPLICIT/OVERT

10. G IVE G ET Autonomy Protection Entitlement Treat patients Provide quality care (personally defined) Traditional Implicit Doctor Compact

11. Management Reinforced Doctors’ Expectations Expectations (psychological contract) consciously and unconsciously developed during doctor training Expectations largely met once in practice – by doctor colleagues and managers Managers reinforced this compact though their own actions and inactions

12. Autonomy Protection Entitlement Improve safety/quality Meet targets Provide service when needed; be flexible Reduce waste Engage in process redesign or lean Follow protocols Delegate to other clinicians Traditional “Promise” Legacy Expectations Imperatives Clash Of “Promise” And Imperatives

13. Observation To the extent the old compact …or shadow of it…still operates as unspoken expectations, it SLOWS innovation, change and ability of the organisation to response to new demands on it Change happens slowly and is experienced by many as loss “I didn’t come here for that. This isn’t the organisation I joined!”

14. NHS England: “The Politics of the Double Bed” Rudolf Klein The medical profession: –Accepted govmn’t right to decide NHS funding level –Retained clinical autonomy and self- regulation The government: –Did not seek to influence clinical decisions –Handed responsibility for deciding priorities to doctors to manage in the privacy of their surgeries and clinics In 1948, at the creation of the NHS, the deal between doctors and the government was:

15. Old Compact Has Been Chipped Away Over the years: More accountability, external review of doctors Inclusion of patients in decisions once only doctors made Protocols, standard work Insistence on real teamwork Patients increasingly expect service BUT NO ONE TALKS ABOUT THE BROKEN “PROMISES”

16. A Possible Future Compact Prof Peter Degeling (2003) Doctors Give Acknowledge resource rationing implications of clinical decisions Balance autonomy with accountability Systematised clinical work Power sharing through teamwork Doctors Get Acknowledgement that resource decisions have clinical impact (e.g. less centrally decided targets) Less government “intrusion” and top down inspection Reduction of risk – clinical and personal Greater support – less sense of ‘I am on my own”

17. Q&A session (1) Dr Jack Silversin Chaired by Dr Alan Willson Please send us your questions and comments using the Q&A panel on WebEx or tweet them with #1000lives @1000livesplus

18. Part 2 Topics How does one create a new compact? What role do doctors play? Management? Trustees?

19. Talk About Expectations When old deal crumbles without conversation, anger and frustration result Dialogue about what is changing and why accelerates support for new deal, new behaviors

20. Preconditions for Successful Compact Process There is some urgency for change Doctors and management share the same understanding of the changing landscape The compact is seen as a tool to achieve the a destination or vision desired by all There is sufficient trust between doctors, doctor leaders and managers to engage in honest dialogue

21. Compact Needs Context Societal needs Government policy Hospital’s strengths Context: Shared Aim or Destination Doctors give : What the org needs to make progress toward shared destination Board gives: What will help doctors to meet their commitment

22. Sample Compact What doctors give: Put patients first Follow accepted best practices Be flexible to innovative practice models Stay informed, be involved Demonstrate respect for all Collaborate with colleagues across departments and settings What doctors get: Include doctor leaders in significant decisions Be transparent regarding finances and decisions Demonstrate appreciation for doctors’ contributions Ensure smooth operations with provider-friendly systems Set clear priorities and provide focus to minimize change fatigue

23. Virginia Mason Medical Center Physician Compact Organization ’ s Responsibilities Foster Excellence Recruit and retain superior physicians and staff Support career development and professional satisfaction Acknowledge contributions to patient care and the organization Create opportunities to participate in or support research Listen and Communicate Share information regarding strategic intent, organizational priorities and business decisions Offer opportunities for constructive dialogue Provide regular, written evaluation and feedback Educate Support and facilitate teaching, GME and CME Provide information and tools necessary to improve practice Reward Provide clear compensation with internal and market consistency, aligned with organizational goals Create an environment that supports teams and individuals Lead  Manage and lead organization with integrity and accountability Physician ’ s Responsibilities Focus on Patients Practice state of the art, quality medicine Encourage patient involvement in care and treatment decisions Achieve and maintain optimal patient access Insist on seamless service Collaborate on Care Delivery Include staff, physicians, and management on team Treat all members with respect Demonstrate the highest levels of ethical and professional conduct Behave in a manner consistent with group goals Participate in or support teaching Listen and Communicate Communicate clinical information in clear, timely manner Request information, resources needed to provide care consistent with VM goals Provide and accept feedback Take Ownership Implement VM-accepted clinical standards of care Participate in and support group decisions Focus on the economic aspects of our practice Change Embrace innovation and continuous improvement Participate in necessary organizational change

24. A New Compact Road Map: Principles Involve as many doctors as possible Hold small group conversations Structure discussions to allow individuals to air what they feel they are losing Connect the compact work to larger vision that resonates with doctors, managers and all other staff Give it time. People need to process their feelings. This is an adaptive change.

25. Decide and communicate the process for developing the compact - including who will be the final decision-maker(s) A sub-group drafts a compact (a straw dog) for others to improve All parties engage in “deep conversation” about what’s included in the compact and why The compact dialogues allow ample opportunity to work through what potentially is lost and what’s gained Finalized and adopted Implementation plans A New Compact Road Map: Steps

26. Some Ways to Make Compact Real Trustees have a role in oversight of management-doctor relations and ensures organisation and doctors and keep their commitments Use compact to recruit and orient new doctors and new managers Leadership provides feedback to doctors and managers – in real time - when they don’t exhibit behavior consistent with the compact Develop processes for reciprocal feedback. Ensure that the organisation keeps its end of the deal Leaders demonstrate their commitment through their own behaviors Address a vexing problem by applying the new compact

27. Compact Process Recalibrates Expectations Journey as important as destination Iterative process for understanding and buy-in…fair process Mutual accountability … doctor to group and group to doctor “We all change”

28. Doctors and Quality Improvement: From Islands to Way of Working There is no magic bullet to get from sporadic, inconsistent and optional doctor engagement with quality to it being THE “way of working”

29. Three Strands Essential for Engaging Doctors in Quality 3.Compact: explicit expectations that support the vision 2.Effective clinical leadership; support change, not advocate for status quo 1.A organisational vision or aspiration that is shared None alone is sufficient. All three are necessary

30. Q&A session (2) Dr Jack Silversin Chaired by Dr Alan Willson Please send us your questions and comments using the Q&A panel on WebEx or tweet them with #1000lives @1000livesplus

31. Closing comments Dr Alan Willson The slides and audio of this session will be available on the 1000 Lives Plus website shortly: www.1000livesplus.wales.nhs.uk/dcc