Enter the new executive

Over the past few months I have been helping two clients who have experienced issues with the introduction of new executive manager. The first is an organisation that hired its first ever CEO, after many decades of growth and management by committee. The second is a hospital that has recruited a replacement Director of Nursing, replacing an incumbent that had been in place for many, many years.

In both instances, the organisation experienced unrest and discontent as a result of the new appointments. This is not entirely unexpected. Whenever a new person arrives it creates a discord. Different experiences create different perspectives which lead to different management practices. Everyone involved is forced to adapt somehow.

Just because the discontent is unexpected does not mean it cannot be managed and the disruption minimised. In both instances the disruption in each of these organisations could have been minimised through better communication with stakeholders, in particular the existing management team. In both instances the repair work was as a result of improved communication. It's a funny word communication it just keeps cropping up!

In the instance of a new CEO being introduced, especially when there hasn't been a CEO in the past, everyone will be impacted upon. The collegial management style of the past will likely change. Decisions may be made faster. Due to the decisionmaking being delegated to a single individual there may appear to be less consultation, though the reality may be different to the perception. The Board has a role to play here, ensuring all stakeholders are advised of the appointment, of the strengths and experiences the incoming CEO will bring, expectations of the Board and some indication of the immediate direction and management plans. Secrecy does not aid integration, it actually hinders the incoming CEO as he or she seeks to implement change. Secrecy or a lack of information leads to rumour, innuendo and stalling behavior, all which results in the organisation becoming distracted from its strategy.

A new senior executive joining the ranks of an existing team has to deal with ingrained management behavior. Again change is inevitable. It is rare for an new senior executive to be hired for the purposes of maintaining the status quo. The situation lends itself to introducing change. When a new executive manager is introduced there is a fear factor amongst all existing staff. Some will fear being caught short as their competencies and work practices are challenged. Peers will resent any attempts to move in on their patch. Poor understanding of the role and expectations of the incoming executive may lead to suspicion and blocking behaviour. On the other hand the incoming executive will have their own fears. Depending upon their past experiences they to may fear being found short on experience and knowledge by peers or direct reports. They may feel obliged to meet seemingly unreasonable expectations by the CEO or may not even fully understand what is expected of them. They may face the challenge of having to make unpopular decisions before they have had an opportunity to become known and accepted.

The CEO has a role to play in helping to integrate an incoming executive manager. Again communication is the key. It is important to bring the management group together as a team. The CEO should communicate to the group collectively so that all hear the same message and any assumptions can be challenged. Ensure the entire management group understands why the new manager was hired and what is expected of this person. Discuss and confirm the roles, expecially any changes to the status quo. It doesn't hurt to discuss as a group any shortcomings the new manager may have (and they all have some) so that the group can work together to minimise any impact of those shortcomings. Hiding shortcomings does not help the organisation in any way.

Nurturing those middle managers

It has been stated that middle managers are the glue that holds an organisation together. Well okay, we will live with the generalisation. It is also possible that were there much better collaborative and participative management processes in place then there would be less requirement for middle managers, and for many senior managers for that matter!

Regardless of whether your organisation is the traditional command and control model or whether it operates within a flattened hierarcy , you will have some middle managers, or supervisory staff. They are important. They form the link between management and staff. They are the implementers of strategy. Executives design strategy but they rely upon the skills of their middle managers to build collaborative relationships with staff, to sell the benefits, to negotiate the change process and to provide feedback that enables adaptation. Without middle managers, the traditional organisation would grind to a standstill.

Yet this group of managers remain the most maligned and mistreated individuals in an organisation. They are between a rock and a hard place. Neither management nor staff. Unable to be loyal to any faction other than themselves. Some 20 percent of middle managers will eventually progress into an executive role. Another 20 percent will drop back into a staff role. This leaves 60 percent that will remain in a middle management role; for better or for worse. It is in the interest of the organisation to ensure those 60 percent are effective.

Just as there are numerous examples of ineffective senior executives creating blockages to progress, there are also examples of middle managers doing the same. The difference is that a senior executive will likely be found wanting when they are monitored for their ability to plan and implement strategy far quicker than a middle manager who is often protected by a senior executive. Of course, the removal of a senior executive that has been shielding a middle manager can result in the middle manager becoming exposed to the scrutiny of an incoming manager. It is doubtful an ineffective middle manager would survive such scrutiny.

The problem for organisations with middle managers is that only a small percentage of supervisors will progress into an executive role. In some organisations it will be less than the suggested 20 percent. This can lead to either a high turnover of middle managers or stagnation fueled by frustration, which in turn, leads to mediocrity. Those middle managers on the bottom of the heap, the blindingly obvious bad managers will out themselves and slide back into the ranks of general staff. The challenge for organisation is this. How can they get the best out of their middle managers?

It is recommended all middle managers have a mentor, or two, or three. Different mentors serve best at different times or in different circumstances. The benefit of mentoring is widely understood, however it is a relationship the middle manager needs to instigate. Mentors rarely present themselves to a manager. You have to approach them with the idea. Mentoring relationships are build upon mutual respect, the mentors understanding of your workplace environment and a willingness by the manager to be open and honest.

Management coaching can be expensive and has traditionally been reserved for the ranks of senior executives or up and coming middle managers on a fast track to the corner office. This needs to change. Our experience of providing coaching to middle managers has always been positive. Traditional practice suggests executive managers benefit most from coaching. Our experience is that many senior executives have become entrenched in their behaviors and find it difficult to acknowledge their faults after they have gained higher office. Middle managers, on the other hand, still have progress available to them, they have more to gain from coaching and are likely to offer more back to the organisation as a result. Effective organisations will remove ineffective middle managers and provide coaching to those in this role; simply because good management behavior developed during middle management years transfers to good executive behaviour in later years.

We persist with the belief that managers are born not made - well at least we do when it comes to providing management training. It appears that we believe any manager worth their salt will develop competencies by osmosis. This is partially true, much management competency is the result of accumulated experience. In the past, when managers took many years to work their way up through the system, this was very true. In today's workplace we promote the majority of managers on demonstrated competency rather than longevity. The result is many managers are younger and have not had the opportunity to accumulate experience. So what do we do? We send them away to residential management courses to learn the theory. Yes while there they engage in role places and situational game play, but these are no substitute for practical experience. Dont misunderstand. Management training, and ongoing training is essential, some would even suggest critical. The key is to apply critical analysis to those providing the training. Look for trainers with practical experience to back up the theory. Look for trainers with practical experience rather than just case studies. Look for trainers able to blend theory, case studies and their practical experience. Look for trainers that follow up their training with coaching, so as to increase the potential for implementation of concepts and methods.

Do organisations need middle managers? Yes they do. Do they need a lot of middle managers? No they should minimise the number of middle managers by creating more collaborative and participatory workplaces at all levels (very scary for senior executives). The outcome of this will be more effective middle managers and more effective senior executives and this will lead to more effective organisations.

The secret to successful teams

I recently came across this nugget of wisdom, contained in one of the numerous newsletters and websites that come into our consultancy daily.

In the United States an annual top leadership team competition is hosted by HealthLeaders Media, aimed at idenitfying the most effective management teams in the health sector. Jim Molpus, from HealthLeader Media was asked, what are the secrets of top management teams?

Guess what his answer was. There are no secrets. Well buggar me, that's two of us in the world who understand that there hasn't been anything new in management techniques or strategies since the days of Aristotle. Despite the best efforts of publishers, the media and the ever-growing corps of self-styled, management gurus - the truth is out, there are no secrets. There is just common sense applied to tried and true processes of communication. For those that doubt me on this, try reading (or rereading) management books by Peter Drucker and Charles Handy. I know you will find them far more relevant and useful than anything else that has been published in the past twenty years.

There are however consistencies that appear in effective management teams and the people at HealthMedia have picked up on these over the years, and I am happy to share them with you here.

• Consistency--Many of the winning Top Leadership Teams have had their core of senior leaders together for a period of several years, as many of the worthwhile goals in healthcare take as long to achieve.
• No tolerance for silos--Winning Top Leadership Teams have found ways to break down traditional silos and barriers that can block healthcare organizations from achieving their goals.
• Strong at the top, but not dominant--Winning leadership teams have highly-effective CEOs. But we have found that almost every winner over the first four years has had a CEO who delegated key strategic responsibilities to top team members, held them accountable for achieving these goals, but ultimately stayed out of the way.
• Transparent--Winning teams in healthcare have to be transparent about what they are doing, who is doing it, and how success or failure is measured.
  
• Be a quality organization--Top Leadership Teams create high quality organisations
  

How well does your organisation rate? The following are some of the things the competition judges look for when reviewing entries into the competition -

• Teamwork exhibited among an organization's senior leaders to achieve stated operational goals/objectives
• How a senior leadership team works together to effectively overcome any challenges/barriers encountered along the way to reaching its goals/objectives
• The success of senior leadership in meeting the team's goals/objectives

I am interested to hear from anyone reading this blog entry. How does your organisation rate on the above criteria. Rate your organisation from 1 - 7 with 1 suggesting your organisation is about to do a 'warley' and disappear into the ranks of health providers that are no more and 7 meaning your CEO has just been invited to speak to an international conference on hospital management.

I would hope you would email me your ratings and criteria. I will keep the information to myself, or if I did use it I would seek permission first to do so.

Here are the criteria again -

1. How well does your management team achieve stated goals and outcomes? 1 - 7
2. How well does your management team work together to overcome barriers on its way to achieving the goals and outcomes? 1 - 7
3. How well does your management team actually work as a team? 1 - 7
4. How well does your team retain its core members over a prolonged period? 1 - 7
5. How good is your management team at dismantling 'silo's and creating cross-functional collaboration? 1 -7
6. How well does your CEO delegate tasks to key executives and hold them accountable for the outcomes? 1 -
   
7. How well does your management team maintain transparency by monitoring outcomes and communicating successes and failures throughout the organisation? 1 - 7
8. A quality organisation is one where all the above occur, where innovation and continuous improvement is encouraged and celebrated, where employees at all levels would recommend their friends work there and where ethical standards are met at all levels. How well would you rate your organisaton as a quality organisation? 1 - 7

I look forward to hearing from you.

GP Waiting Lists

The Australian Federal Government has announced it plans to publish details of waiting lists. This is one piece of information consumers would like to see. The single biggest complaint about the health system is how long it takes a patient to recieve treatment. It is preferable to provide information on waiting times than on the numbers of people waiting for treatment.

I wonder how this information will be presented? Will it be presented in a manner that makes it useful for consumers? How will the hospital sector use this information? Will it reduce the actual waiting lists? Will health funding be tied into reducing waiting lists? Why should a hospital be funded to provide a service and then retain that funding when it fails to deliver? Will the waiting list information distinguish between in-patients and out-patients?

Logically the information should be broken down by State and then by hospital. There are difficulties in doing this however. Not all hospitals provide all services and in breaking down to the individual hospital inequities and anomolies might be created. It would be helpful to have the waiting list broken down by surgical procedure. The issue with aggregating State information is that it becomes difficult to hold individual hospital administrations to account.

Perhaps the Federal Government should also look at publishing details of the waiting list for those with private health insurance and seeking care in the public system and those without private health insurance. In this way it might be possible to identify the level of queue jumping that is percieved to take place. Likewise information on the number of surgical procedures that were 'rescheduled' and the reason for that would help also to induce a sense of accountability within hospitals. If rescheduled surgery information was provided, would the waiting times be accumulated for each patient or would only the shortest, most recent period of time be recorded?

Ten years ago, in 1997, in NSW, it was reported that there were often two waiting lists. One held by GP's and one maintained by surgeons. Perhaps the Government could collect data showing the differences between the information provided to GP's and what actually takes place.

Reducing waiting lists is important to consumers. There are records of people actually dying or suffering greater illness while waiting to recieve treatment. At the same time consumers have few options as to which hospital they might go to and recieve treatment. Yet that is not sufficient reason not to collect and publish data. Consumers pay for hospitals, they have a right to information on performance. Hospital adminstrators have an obligation to spend public money in an effective manner.

What might the Federal Government do with this information? There is little evidence to suggest that spending increased amounts on infrastructure and or additional specialists will actually reduce waiting lists. There is a straightforward reason for this. Specialists will act to protect their own interests. The answer may lie in removing the final decision from the specialists. Hospital waiting lists are also a necessary evil. Considerable investment is made in infrastructure, staffing and equipment. These resources cannot be allowed to remain idle. The aim should not be to eliminate waiting lists, rather to minimise the time an outpatient spends waiting for treatment. While decisions will always need to be made on a individual case basis, there is evidence that minimum waiting times can be introduced and maintained.

The case for minimising waiting lists is not a one way street. Consumers also have to take responsibility for their behaviour. When a patient doesnt turn up, as scheduled, for an appointment or procedure, they have effectively wasted an opportunity, not only for themselves, but they may also have contributed to someone else's misfortune. If hospital administrators are to be penalised for poor performance then it is reasonable to suggest consumers should also be penalised for poor performance.

GP's themselves may have to take greater accountability for their actions. GP's cannot treat every health issue, therefore they refer patients to specialists. How may times is this done for convenience sake? The Federal Government has clearly set out its priority and focus upon primary health care. Is it possible GP's might collaborate more with the primary care sector and perhaps consider referring patients in this direction, for preventative action, rather than automatically referring to a specialist? This might have a double benefit in that it may contribute to reduced waiting lists while also helping patients take greater responsibility for their own health outcomes.

Maybe it is time for greater collaboration between hospitals within States and between various State health sectors. Collaboration may lead to improved utilisation of resources within hospitals. Not every hospital in the country is fully utilised at the same time. While this would mean some consumers having to recieve treatment away from their home region - at least consider giving them the option. For some consumers the option of treatment now in another state would be preferable to waiting on a list for an unknown period of time.

Performance monitoring in hospitals

The Australian Federal Government has reached agreement with State Governments to implement reciprocal performance reporting of public hospitals. This is a step in the right direction. It is not possible to improve performance without first collecting data for analysis. The reality is, of course, that hospitals already collect vast amounts of information about themselves. It might be that collecting the data is not the issue, the real issue might be that they chose not to act upon the information they collect.

Talk is cheap. In the past the State Government's have not been keen to be placed under scrutiny through performance monitoring. The New South Wales State Government has been particularly opposed to the idea. Only time will tell as to what the performance measurements will be, and how well the State Governments support the process.

In theory all hospitals should be the same. This suggests measurement parameters would provide comparable information. In theory consumers should be able utilise the information provided through monitoring to help them choose where they would like to go for care. The reality is different to the theory. Often consumers have little option where they go for hospital care. Even for those with private health insurance, freedom of choice, long touted by private insurers, is limited by the availability and location of services. Politically it may not be in any Governments best interests for its health service to come under close public scrutiny.

Consumers want certain information. For example, they want to know that hospital waiting lists are becoming shorter. They want to know about the safety record within hospitals. They want to know which hospitals experience outbreaks of infection within the hospital. They want to know which hospitals experience high levels of deaths by accident.

Hospital administrators also need information. They need to know what their patients think of their service. They need to know the level of staff turnover, the average length of hospital stay, the time taken for triage, the number of day procedures, financial data, the level of in-hospital infection, bed availability, number of surgical procedures. Much of this information is already collected within hospitals.

Hospitals have expressed reservations about the validity of 'league tables' comparing one hospital against another. Such reservations are often well founded, except, that is when the hospitals use the shortcomings of league tables to avoid overall scrutiny. There does not appear a lot of evidence to support the theory that creating league tables leads to improved productivity. League tables imply all hospitals are equal. They may well have been created equal but they do not operate in equitable environments. League tables do not take into consideration additional, regional, factors that individual hospitals may have no control over. It is unlikely league tables will provide consumers with usable information.

Consumers may not want ‘league’ tables. Tables can make for interesting, and sometimes controversial fodder for the media, however consumers have neither the time nor the inclination to analyse such tables. It is not even a given that consumers want raw data. It is possible all they require is reassurance the processes designed to minimise the impact and maximise the benefit to them are in place.

New Zealand health targets

At the commencement of the 2007/2008 financial year the New Zealand Government, in conjunction with District Health Boards, introduced health targets. The objective being to improve universal access to health services throughout the country, to all sectors of the population.

Health targets focus upon 10 areas, these being:

1. Improving immunisation coverage
2. Improving oral health Improving elective surgery
3. Reducing cancer waiting times
4. Reducing ambulatory sensitive (avoidable) hospital admissions
5. Improving diabetes services
6. Improving mental health services
7. Improving nutrition, increasing physical activity and reducing obesity
8. Reducing the harm caused by tobacco
9. Reducing the percentage of the health budget spent on the Ministry of Health

District Health Boards and the Ministry of Health are jointly responsible for working together to achieve target outcomes. Targets are negotiated for each District Health Board (DHB) area.

First quarter results were published in November 2007. Second quarter results are due around April 2008. These showed progress being made. In short, off the ten health targets set, eight were on track and two showed progress, however in these two instances, issues of data collection or implementation created difficulties in meeting targets.

It is noticeable these target areas appear not to include any direct focus upon the impact of excessive alcohol and drug use! Target areas 1, 2, 5, 8 and 9 have a primary care focus, where the aim is to help consumers take increased responsibility for their own health and consequently reduce the level hospital admissions. Achievement of these targets has a double benefit. The overall health of the population improves and the cost of providing public health services is reduced. There is a flip side to a healthy population. Healthy people live longer, thus increasing the cost of aged care.

The two areas where progress was made, but targets not achieved, were (3) improving elective surgery and (6) improving diabetes services. The measurement tool for improving elective surgery is the Elective Surgery Performance Indicator (ESPI). This measures the flow of patients through the hospital system. This target area is of particular interest to consumers as it measures the time those in need of surgery spend on the waiting list. ESPI’s go to the heart of productivity processes within a hospital.

There are three target areas within the health target for improving diabetes services. These include, free annual diabetes checks, good diabetes management and retinal screening.

One quarter of reporting does not an improvement maketh. In other words it is early days. Clearly some District Health Boards are experiencing difficulties establishing a quarterly reporting process. Given the Governments advance notice of health targets and the consultation process prior to their establishment, there is no excuse for quarterly reporting processes not being in place. Not having achieved this is a failure of management. Those District Health Boards experiencing such issues include two of the largest in the country, Auckland and Canterbury. The fact that significantly smaller DHB’s with lesser resources are able to achieve such processes doesn’t bode well for the larger ones.

It would be a reasonable expectation that all DHB’s would have in place quarterly reporting processes in time for the second quarter reports. The longer DHB’s take to achieve this, the more reason they provide both Governments and consumers with reason to ask why? A lack of transparency can lead to speculation, which is often incorrect, and can also lead to a suggestion that these DHB’s have something to hide.

Australia moves towards primary health care

The Rudd Government health strategy signal a move towards increased expenditure on primary health care. This assumes the consumer will take greater responsibility for their own health. It also suggests an increased level of expenditure by the Federal Government on creating awareness amongst the public off the consequences of poor nutrition, low levels of exercise, excessive imbibing and inadequate self care.

A recent media release by Federal Minister for Health and Ageing, Nicola Roxon, outlined the following:

• National Preventative Health Strategy to tackle issues of alcohol, tobacco and obesity
• An increased focus on preventative health care to be included in Australian Health Care Agreements with the State Governments.
• A review of the Medicare fee schedule

With the exception of the review of Medicare fees, which may or may not, increase the cost to the Federal Government, the other two outcomes require substantial, and prolonged investment, in creating public awareness. As has been witnessed by the billions spent over decades to create awareness of issues associated with driving motor vehicles, it will likely take the same level of investment, maybe even greater, to shift the perception of the public away from their current expectation that the health system will cater for all their needs; to a perception where each individual takes personal responsibility for their own health outcomes.

As suggested in an earlier entry to this blog, one impediment to consumers taking responsibility for their own health outcomes is the perceived low cost of health care. It would be easy to simply suggest the Government should increase the cost to the individual in an effort to discourage each of us from living decadent lifestyles. This is unlikely to be effective. Our past experiences with raising direct costs associated with motoring, smoking and drinking alcohol have shown that such increases rarely, if ever, have a sustained impact upon consumption. On the other hand, extended and comprehensive public campaigns have served to raise awareness amongst consumers.

If, as the Government appears to believe, the answer lies in primary care, in creating increased awareness, in providing information and education and in the consumer taking responsibility for their own health outcomes, then the program to achieve this is likely to consume the major slice of health spending by the Federal Government.

Add to this an expectation that each State Government will increase their focus on preventative health, suggests also that a significant portion of State Government spending on health will be directed towards education and public awareness. For every dollar spent on preventative health, one less dollar is available to spend on maintaining and expanding the hospital sector.

Now here is the rub. Assuming the Rudd Government has set the correct long-term strategy and assuming State government health ministers will be able to stand the heat and maintain a good working relationship with Federal ministers and assuming subsequent Federal Governments continue in this direction then at some point in the future people will spend less time visiting their GP or specialist and less time in hospital. At that point the savings from reduced health costs may equal the cost of Medicare. When this occurs both the cost of maintaining Medicare and the public hospital system will become sustainable.

In setting this direction the Rudd Government has lifted the lid on the Pandora’s Box of public healthcare and it may not be possible to ever put the lid back again. It is possible, the consequences of this direction, though not highly visible at present, may revolutionise public health delivery throughout Australia for ever.