1. Health and Everything Performance Management Insight September 27, 2006 The Old Mill

2. Health and Everything Notes No need to take notes This presentation and a lot more material is on these issues is available on our web site www.healthandeverything.org For more information you can write to me sholom@glouberman.com

3. Health and Everything The NHS The Blair government created strategic health authorities (SHAs) in 2002 specifically to performance manage the newly created primary care trusts (PCTs). There was thus a four year experiment with a large scale performance management effort worth looking at.

4. Health and Everything Performance Management NHS 2002-2005 Minister of Health Department of health 28 Strategic Health Authorities 180 Acute and Mental Health Trusts 200 Primary Care Trusts 1.000.0000 Employees

5. Health and Everything My Role I have been meeting semi-annually with a representative cross section of the NHS from 1990 to review the state of play and changes that have occurred I consulted to a strategic health authority from 2001 to 2005 –I met with them 4 times a year to see how they were doing and lend a hand in their efforts. I also consulted to a Primary Care Trust from 2001 to 2003 –I met with them 5 times and helped with their planning efforts

6. Health and Everything Introducing Performance Management in the UK A specific publication on performance management was prepared in 2002, but is no longer available on the internet or in hard copy So I have used standard sources to give an overview of Performance Management Various Outlines and Reports are available that helped to describe how it was implemented in the NHS

7. Health and Everything Performance management Performance management is the systematic process by which an organization involves its employees, as individuals and members of a group, in improving organizational effectiveness in the accomplishment of its mission and goals.

8. Health and Everything Employee performance management includes: Planning work and setting expectations, Continually monitoring performance, Developing the capacity to perform, Periodically rating performance in a summary fashion, Rewarding good performance. PlanningMonitoring Rewarding Rating Developing

9. Health and Everything Employee performance management includes: PlanningMonitoring Rewarding Rating Developing

10. Health and Everything Planning Set performance expectations and goals Involve employees in the planning process –help them understand goals (what why and how) Establish elements and standards of performance appraisal –that are measurable, understandable, verifiable, equitable & achievable. Hold employees accountable as individuals Plans should be flexible Plans should be discussed often and not seen only when formal ratings are required. Planning

11. Health and Everything Planning in the NHS: Trust Involvement Introduction of 3 year Local Delivery Plans to be prepared by individual trusts –Bottom up planning to involve all local agencies with support from the SHA –Stabilization of planning and funding over 3 year periods Planning

12. Health and Everything Monitoring Monitor continually. Consistently measure performance Provide ongoing feedback on progress toward goals. Compare performance against their elements and standards. Change unrealistic or problematic standards Identify and correct unacceptable performance quickly Monitoring

13. Health and Everything Monitoring in the NHS Three Major agencies to monitor and assess the system NICE: National Institute for Clinical Excellence –To review standards and improve clinical practice CHI: Commission for Health Improvement –To consider impact on health of the nation Audit Commission –To monitor and assess fonancial and operational management Monitoring

14. Health and Everything Developing During planning and monitoring of work –Deficiencies become evident and can be addressed –Successful employees can be helped to further improve Evaluate and address developmental needs Increasing capacity to perform through training, Give assignments to introduce new skills or higher levels of responsibility, Improve work processes The above encourage good performance –Strengthen job-related skills –Help employees keep up with changes in the workplace Developing

15. Health and Everything Developing in the NHS Creation of the “Modernization Agency” –Seconded the best development officers –To help define the shape of the “New and modern NHS” –Then to identify and develop the new skills and competencies needed for the new NHS –To identify and deal with development issues quickly Developing

16. Health and Everything Rating Organizations need to know who their best performers are. Rating allows you to compare performance over time or among various employees. Evaluates employee or group performance against the elements and standards Assigns a summary rating of record for each employee. –based on work performed during an entire appraisal period. –has a bearing on various other personnel actions granting within-grade pay increases determining additional retention service credit in a reduction in force. Rating

17. Health and Everything Rating in the NHS An Annual Report on the performance of individual organizations –Linked to the measurable targets –Uses a three star rating system 0 stars = poor to 3 stars: excellent Individual Managers and organizations are rated using these performance measures at every level of the system Rating

18. Health and Everything Rating in the NHS: 45 Measurable Targets Key target A&E emergency admission waits (12 hours) Cancelled operations not admitted within 28 days Financial management Hospital cleanliness Improving Working Lives Number of inpatients waiting longer than the standard Number of outpatients waiting longer than the standard Total time in A&E Two week cancer waits Capacity and capability Consultant appraisal Data quality Fire, Health & Safety Information Governance Junior doctors' hours Sickness absence rate Staff opinion survey Clinical focus Clinical Negligence Deaths within 30 days of a heart bypass operation Deaths within 30 days of selected surgical procedures Emergency readmission to hospital following discharge Emergency readmission to hospital following discharge for children Emergency readmission to hospital following treatment for a fractured hip Emergency readmission to hospital following treatment for a stroke Infection control procedures Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia improvement score Thrombolysis treatment time Patient focus A&E emergency admission waits (4 hours) Better hospital food Breast cancer treatment Cancelled operations Day case booking Delayed transfers of care Nine month heart operation waits Outpatient A&E survey - access & waiting Outpatient A&E survey - better information, more choice Outpatient A&E survey - building relationships Outpatient A&E survey - clean, comfortable, friendly place to be Outpatient A&E survey - safe, high quality, co-ordinated care Paediatric outpatient did not attend rates Patient complaints procedure Privacy & dignity Six month inpatient waits Thirteen week outpatient waits Total inpatient waits Waiting times for Rapid Access Chest Pain Clinic Planning

19. Health and Everything Rewarding Recognize employees, individually and as members of groups, Acknowledge contributions to the mission All behavior is controlled by its consequences –formal and informal –positive and negative. Informal recognition is constant and ongoing like saying "Thank you“ More formal rewards include cash, time off, and many non-monetary items. Rewarding

20. Health and Everything Rewarding in the NHS The main group reward in the NHS is through the creation of Foundation Trusts Individual organizations that have far more independence and can increase their local rather than national reporting relationships This is replicated inside SHAs and indeed inside the existing trusts –Successful managers move up quickly –A successful CEO of an SHA received a knighthood Rewarding

21. Health and Everything 2006 In 2006 the Ministry of Health reduced the number of strategic health authorities to 14 and radically changed the primary care trusts. They merged the monitoring agencies Performance Management is no longer the flavour of the month How did it all go so wrong? Not that anyone admits it.

22. Health and Everything Planning in the NHS: Trust Involvement The 3 year Local Delivery Plans (LDPs) took two years to frame –Local trusts did not perform well –The SHAs believed that they did not have the planning capacity to prepare the extensive documentation. LDPs were renewed annually LDPs were required top down and the bottom up was to get them done in an acceptable way Annual revisions reduced the stability that was expected The SHAs could not performance manage trusts adequately and were therefore largely merged into larger less directive organizations What would bottom up planning be in the NHS? Planning

23. Health and Everything Planning in the NHS: Targets The priority targets were largely met or fudged. –Some incidents of faking data –Some incidents of meeting stated targets but subverting the real meaning –Widespread hidden overspend Government boasted of success in reducing all waiting times Head of NHS was fired for £1Billion accumulated deficit that emerged suddenly What does measurable really mean? Planning

24. Health and Everything Monitoring in the NHS Three Major agencies to monitor and assess the system disagreed about the state of individual trusts that they examined They functioned as largely independent and somewhat competing inspectorates They disagreed about what the standards meant They also overloaded individual trusts with monitoring demands They were merged into one organization that is now much more hierarchically connected to the Ministry. Monitoring

25. Health and Everything Developing in the NHS The Modernization Agency was disbanded in 2005 –(The government declared it to be a success and closed it down) The best development officers had been stripped from local organizations and now would not go back The performance management of development issues was largely done through punitive measures at the SHA rather than the Modernization Agency. –Many executive level managers of trusts lost their jobs. The failure to perform “old skills” like those associated with budget management was widespread Developing

26. Health and Everything Rating in the NHS The Annual Report was awaited with bated breath because your job depended on it –Linked to the priority targets so other non-targeted areas suffered –Targets continue to be attacked constantly –The three star rating system had its downside 0 stars pretty much meant that at least the CEO was fired 3 stars meant that you became high profile Individual Managers and organizations are rated using these performance measures at every level of the system Rating

27. Health and Everything Rating in the NHS

28. Health and Everything Rating in the NHS Key targets A&E emergency admission waits (12 hours) Cancelled operations not admitted within 28 days Financial management Hospital cleanliness Improving Working Lives Number of inpatients waiting longer than the standard Number of outpatients waiting longer than the standard Total time in A&E Two week cancer waits

29. Health and Everything Rewarding in the NHS The main reward in the NHS is through the creation of Foundation Trusts –There is a serious question about how these organizations link to the rest of the NHS –This has consequence to everything from funding flow to patient flow. Individual organizations that have far more independence and can increase their local rather than national reporting relationships There is much talk about the future of these organizations Punishment for failure seems more in the air motivator than reward for success The knighted head of the NHS Sir Nigel Crisp lost his job over these efforts Rewarding

30. Health and Everything The Law of Unintended Consequences With all good intentions this massive effort to implement performance management failed Does this mean that performance management will go the way of other similar management ideas? Why did it fail? Can it be recuperated? Or should it simply cross the ocean to be implemented in Ontario? I have some closing thoughts

31. Health and Everything Following a Recipe A Rocket to the Moon Raising a Child Formulae are critical and necessary Sending one rocket increases assurance that next will be ok High level of expertise in many specialized fields + coordination Rockets similar in critical ways Relative certainty of outcome Optimism re results Formulae have only a limited application Raising one child gives no assurance of success with the next Expertise can help but is not sufficient Every child is unique Uncertainty of outcome remains Optimism re results ComplicatedComplex The recipe is essential Recipes are tested to assure replicability of later efforts No particular expertise; knowing how to cook increases success Recipes produce standard products Certainty of same results every time Optimism re results Simple

32. Health and Everything Analysis Health care organizations and systems are complex Recipes won’t work and their application will have unintended consequences Performance management like many other flavours of the month can be useful but should be applied with great care and foreboding while carefully considering the complexity of local conditions