HEALTH SERVICES AND DELIVERY RESEARCH

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1 HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 1 ISSUE 4 JUNE 2013 ISSN How do they manage? A quaitative study of the reaities of midde and front-ine management work in heath care DA Buchanan, D Denyer, J Jaina, C Keiher, C Moore, E Parry and C Pibeam DOI /hsdr01040

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3 How do they manage? A quaitative study of the reaities of midde and front-ine management work in heath care DA Buchanan,* D Denyer, J Jaina, C Keiher, C Moore, E Parry and C Pibeam Cranfied University Schoo of Management, Cranfied, Bedfordshire, UK *Corresponding author In memoriam Decared competing interests of authors: none Discaimer: This report contains transcripts of interviews conducted in the course of the research and contains anguage that may offend some readers. Pubished June 2013 DOI: /hsdr01040 This report shoud be referenced as foows: Buchanan DA, Denyer D, Jaina J, Keiher C, Moore C, Parry E, et a. How do they manage? A quaitative study of the reaities of midde and front-ine management work in heath care. Heath Serv Deiv Res 2013;1(4).

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5 Heath Services and Deivery Research ISSN (Print) ISSN (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) ( Editoria contact: The fu HS&DR archive is freey avaiabe to view onine at Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: Criteria for incusion in the Heath Services and Deivery Research journa Reports are pubished in Heath Services and Deivery Research (HS&DR) if (1) they have resuted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficienty high scientific quaity as assessed by the reviewers and editors. HS&DR programme The Heath Services and Deivery Research (HS&DR) programme, part of the Nationa Institute for Heath Research (NIHR), was estabished to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Heath Services Research (HSR) programme and the Service Deivery and Organisation (SDO) programme, which were merged in January The HS&DR programme aims to produce rigorous and reevant evidence on the quaity, access and organisation of heath services incuding costs and outcomes, as we as research on impementation. The programme wi enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evauative research to improve heath services. For more information about the HS&DR programme pease visit the website: This report The research reported in this issue of the journa was funded by the HS&DR programme or one of its proceeding programmes as project number 08/1808/238. The contractua start date was in January The fina report began editoria review in Juy 2012 and was accepted for pubication in January The authors have been whoy responsibe for a data coection, anaysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors report and woud ike to thank the reviewers for their constructive comments on the fina report document. However, they do not accept iabiity for damages or osses arising from materia pubished in this report. This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views and opinions expressed by authors in this pubication are those of the authors and do not necessariy refect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. If there are verbatim quotations incuded in this pubication the views and opinions expressed by the interviewees are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. Queen's Printer and Controer of HMSO This work was produced by Buchanan et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Pubished by the NIHR Journas Library ( produced by Prepress Projects Ltd, Perth, Scotand (

6 Heath Services and Deivery Research Editor-in-Chief Professor Ray Fitzpatrick Professor of Pubic Heath and Primary Care, University of Oxford, UK NIHR Journas Library Editor-in-Chief Professor Tom Waey Director, NIHR Evauation, Trias and Studies and Director of the HTA Programme, UK NIHR Journas Library Editors Professor Ken Stein Chair of HTA Editoria Board and Professor of Pubic Heath, University of Exeter Medica Schoo, UK Professor Andree Le May Chair of NIHR Journas Library Editoria Group (EME, HS&DR, PGfAR, PHR journas) Dr Martin Ashton-Key Consutant in Pubic Heath Medicine/Consutant Advisor, NETSCC, UK Professor Matthias Beck Chair in Pubic Sector Management and Subject Leader (Management Group), Queen s University Management Schoo, Queen s University Befast, UK Professor Aieen Carke Professor of Heath Sciences, Warwick Medica Schoo, University of Warwick, UK Dr Tessa Criy Director, Crysta Bue Consuting Ltd, UK Dr Peter Davidson Director of NETSCC, HTA, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Dr Tom Marsha Reader in Primary Care, Schoo of Heath and Popuation Sciences, University of Birmingham, UK Professor Wiiam McGuire Professor of Chid Heath, Hu York Medica Schoo, University of York, UK Professor Geoffrey Meads Honorary Professor, Business Schoo, Winchester University and Medica Schoo, University of Warwick, UK Professor Jane Norman Professor of Materna and Feta Heath, University of Edinburgh, UK Professor John Powe Consutant Cinica Adviser, NICE, UK Professor James Raftery Professor of Heath Technoogy Assessment, Wessex Institute, Facuty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Keijnen Systematic Reviews Ltd, UK Professor Heen Roberts Professoria Research Associate, University Coege London, UK Professor Heen Snooks Professor of Heath Services Research, Institute of Life Science, Coege of Medicine, Swansea University, UK Pease visit the website for a ist of members of the NIHR Journas Library Board: Editoria contact: NIHR Journas Library

7 DOI: /hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Abstract How do they manage? A quaitative study of the reaities of midde and front-ine management work in heath care DA Buchanan,* D Denyer, J Jaina, C Keiher, C Moore, E Parry and C Pibeam Cranfied University Schoo of Management, Cranfied, Bedfordshire, UK *Corresponding author In memoriam This project addressed three questions. First, how are midde management roes in acute care settings changing, and what are the impications of these deveopments? Second, how are changes managed foowing serious incidents, when recommendations from investigations are not aways acted on? Third, how are cinica and organisationa outcomes infuenced by management practice, and what properties shoud an enabing environment possess to support those contributions? Data were gathered from around 1200 managers in six trusts through interviews, focus groups, management briefings, a survey with 600 responses, and serious incident case studies. For this project, midde management meant any roe beow board eve that incuded manageria responsibiities. Evidence provided by trust workforce information offices reveaed that the management function is widey distributed, with >30% of hospita staff hoding either fu-time management posts or hybrid roes combining manageria with cinica or medica responsibiities. Hybrids outnumber fu-time managers by four to one, but most have ony imited management training, and some do not consider themseves to be managers. Management capabiities now at a premium incude poitica skis, resiience, deveoping interprofessiona coaboration, addressing wicked probems, performance management and financia skis. Case study evidence reveas mutipe barriers to the impementation of change foowing serious incidents. These barriers reate to the compex causes of most incidents, the difficuties in estabishing and agreeing appropriate action pans and the subsequent probems of impementing defensive change agendas. The concusions from these case studies suggest that the management of serious incidents coud potentiay be strengthened by adding a change management perspective to the current organisationa earning focus, by compementing root cause and timeine anaysis methods with mess mapping processes and by exporing opportunities to introduce systemic changes and high-reiabiity methods in addition to fixing the root causes of individua incidents. Interview, focus group and survey evidence shows that midde managers are deepy committed but face increasing workoads with reduced resources, creating extreme jobs with ong hours, high intensity and fast pace. Such roes can be rewarding but carry impications for work ife baance and stress. Other pressures on midde management incuded rising patient and pubic expectations, financia chaenges, burdensome reguation (externa and interna), staffing probems, incompatibe and dated information systems, resource and professiona barriers to impementing change and probematic reationships with externa agencies. Despite these pressures, management contributions incuded maintaining day-to-day performance, firefighting, ensuring a patient experience focus in decision-making, transating ideas into working initiatives, identifying and seing new ideas, faciitating change, troubeshooting, everaging targets to Queen's Printer and Controer of HMSO This work was produced by Buchanan et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v

8 ABSTRACT improve performance, process and pathway redesign, deveoping infrastructure (information technoogy, equipment, estate), deveoping others and managing externa partnerships. Actions required to maintain an enabing environment to support those contributions woud invove individua, divisiona and organisationa steps, most of which woud be cost neutra. Recommendations for future research concern the assessment of management capacity, the advantages and drawbacks of service-ine organisation structures, the incidence and impications of extreme manageria jobs, evauating aternative serious incident investigation methods, and the appicabiity of high-reiabiity organisation perspectives in acute care settings. Funding: The Nationa Institute for Heath Research Heath Services and Deivery Research programme. vi NIHR Journas Library

9 DOI: /hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Contents List of abbreviations.... Scientific summary... Chapter 1 Aims, background and methods Things can ony get different Research questions Why midde management? Research methods Chapter 2 The NHS management popuation Names, ranks and numbers Pure pays and hybrids Finding the front, defining the midde Concusions and impications Chapter 3 The institutiona context The nature and significance of context The six dimensions The management diemma Chapter 4 The organisationa context The ong to do ist Trust profies Changing structures Management agendas Much doing to be done Chapter 5 The reaities of midde management Introduction The management roe Midde management in heath care Management survey findings Motives and rewards How is the roe changing? Extreme jobs, resiience and job crafting Concusions and impications: reeasing time to manage Chapter 6 Managing change foowing extreme events What's the probem? The management of extreme events Costridium difficie at Burnside Mrs Mayand Mr Torrens Mr Mitcham Managing change in wicked situations ix xi Queen's Printer and Controer of HMSO This work was produced by Buchanan et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

10 CONTENTS Chapter 7 Management contributions Introduction The strategic midde manager Evidence from this study What has to change? A contributions-based mode of management Management in the pura Acknowedgements References Appendix 1 Research protoco Appendix 2 Project documentation Appendix 3 Management survey Appendix 4 Managing the norovirus outbreak at Watte Park Appendix 5 Project outputs Appendix 6 Reated pubications Appendix 7 Sweating the sma stuff: minor probems, rapid fixes, major gains Appendix 8 Research methods viii NIHR Journas Library

11 DOI: /hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 List of abbreviations A&E AGM ALERT CDU CIP CNST CQC accident and emergency assistant genera manager acute ife-threatening events recognition and treatment Cinica Decisions Unit cost improvement programme Cinica Negigence Scheme for Trusts Care Quaity Commission Mid Staffs MRSA NPSA NRLS OFSTED Mid Staffordshire NHS Foundation Trust methiciin-resistant Staphyococcus aureus (heath care-associated infection) Nationa Patient Safety Agency Nationa Reporting and Learning System Office for Standards in Education, Chidren's Services and Skis CSF Comprehensive Sodier Fitness PALS Patient Advice and Liaison Service D&V DIPC FTE HOSC HPA HSE IT LINks diarrhoea and vomiting (norovirus symptoms) Director of Infection Prevention and Contro fu-time equivaent (empoyees) Heath Overview and Scrutiny Committee Heath Protection Agency Heath and Safety Executive information technoogy Loca Invovement Networks PCT PSI RAIAs RCA RTT SDO SHA WHO primary care trust pubic services industry reguators, auditors, inspectorates and accreditation agencies root cause anaysis referra to treatment (18-week target maximum waiting time) Service Deivery and Organisation strategic heath authority Word Heath Organization A abbreviations that have been used in this report are isted here uness the abbreviation is we known (e.g. NHS), or it has been used ony once, or it is a non-standard abbreviation used ony in figures/tabes/appendices in which case the abbreviation is defined in the figure egend or at the end of the tabe. Queen's Printer and Controer of HMSO This work was produced by Buchanan et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ix

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13 DOI: /hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Scientific summary Background Management is a roe traditionay defined in terms of activities, which incude POSDCoRB : panning, organising, supervising, directing, co-ordinating, resourcing and budgeting. Human resource management responsibiities must aso now be added to this ist of activities, as these have been increasingy devoved to ine management aong with change and service improvement roes, which may or may not invove responsibiity for staff and budgets, but which invove panning, organising, co-ordinating and other traditiona management activities, as we as carrying accountabiity for change outcomes. For the purposes of this project the term midde manager encompassed a hospita staff with roes that incuded some or a of these management responsibiities, with the exception of board members. The management function was thus found to be widey distributed, with >30% of hospita staff either hoding fu-time management posts or combining manageria responsibiities with cinica or medica duties. The atter group, hybrids, outnumber fu-time managers by four to one, but most have itte management training, and some do not consider themseves to be managers. Objectives This project was designed in response to a ca for studies of management practice in heath care, and addressed three sets of questions. First, how are midde management roes in acute settings changing, and what are the impications of those trends? Second, what probems arise when impementing change foowing the recommendations of investigations into serious incidents, and how can those probems be effectivey addressed? Third, how are cinica and organisationa outcomes infuenced by management practice, and what properties shoud an enabing environment possess to support and strengthen those contributions? Evidence shows that most management contributions are change and improvement oriented. Impementing change in the aftermath of serious incidents can be seen as a specia and vauabe category of contribution. Methods Data were gathered from 1205 managers in six acute trusts, incuding two foundation and four non-foundation trusts, through set-up and case incident interviews, focus groups, management briefings and a survey that generated over 600 responses from five of those trusts. Quaitative information from interviews and focus groups was anaysed using standard content anaysis to identify recurring patterns of issues and themes. For the serious incident case studies, event sequence narratives were deveoped, based on tempora bracketing and, where appropriate, accompanied by mess mapping to generate visua representations of the antecedents and aftermath of such events in addition to the properties and causes of the incidents themseves. Resuts Interview, focus group and survey evidence shows that midde managers are deepy committed and highy motivated but have to cope with increasing demands and diminishing resources. They aso have a negative stereotype, reinforced by poiticians and the media, devauing their contribution. The extensive and constanty changing nature of acute trust management agendas appears to have created extreme jobs, which are characterised by ong hours, high intensity and fast pace. This job profie can be exciting and Queen's Printer and Controer of HMSO This work was produced by Buchanan et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xi

14 SCIENTIFIC SUMMARY rewarding, but can aso have adverse impications for stress and work ife baance. Other main findings with regard to the three sets of research questions are as foows. Reaities Counting pure pays and those in hybrid cinica-manageria roes, around one-third of hospita staff have manageria responsibiities. This contrasts with NHS Information Centre data, which categorise ony 3% of NHS empoyees as managers and senior managers. This discrepancy is expained by the nature of the Information Centre's coding matrix rues, which categorise midde managers and supervisors as administrative and cerica, and which count those in hybrid roes with their occupationa groups typicay doctors and nurses. Most hybrids have had itte or no management training, hod part-time manageria roes and do not think of themseves as managers, preferring the term eader. Some even fee that being described as a midde manager is demeaning, especiay with government ministers and the media repeating disparaging comments about the vaue of heath-care managers. Acute trusts have engthy, compex, mutioaded change agendas, with mutipe priorities that compete and confict with each other, in which a items are aways priority. A key concern thus ies with the manageria capacity to cope with this workoad. The institutiona context of heath care is highy reguated and prescriptive, with constant structura change and micromanagement from centra government. Even a poicy to encourage innovation in service deivery was accompanied by a new oversight body, a compiance framework and fines for non-compiance conditions that are known to stife innovation. Midde managers are deepy committed and highy motivated but their roes and responsibiities have continued to expand, aong with rising expectations to maintain and improve quaity and safety of patient care, in the context of ongoing cuts in resources. A variation on the extreme jobs phenomenon, first met in highy paid internationa professiona roes in finance and management consuting, now appies to many midde management roes in heath care, with ong hours, fast pace, constant demands and high intensity of work. Exciting for some, extreme jobs can ead to fatigue, burnout and mistakes. Management and eadership capabiities at a premium incude poitica skis, resiience and menta toughness, deveoping interprofessiona coaboration, addressing soft compexity and wicked probems, performance management capabiities and financia management. Changes Experience in heath care and esewhere suggests that it cannot be assumed that findings from investigations into serious incidents and never events wi automaticay be impemented. There are often many individua and organisationa barriers to change in such contexts. Probems with change foowing serious incidents are traditionay conceptuaised as organisationa earning difficuties. Evidence from the cases deveoped in the course of this project suggests that this approach coud potentiay be strengthened by adding a change management perspective, managing change in wicked situations and driving defensive rather than progressive agendas, in which conventiona guideines do not necessariy appy. Widey used in the anaysis of serious incidents, root cause anaysis is a vauabe too. However, in seeking to fix the immediate causes of individua incidents, this approach is imited in terms of estabishing wider-ranging change agendas and has been criticised as eading to root cause seduction. In other sectors, systems-theoretic methods are now more commony depoyed on the grounds that systemic probems require systemic soutions. A maintenance mode of sustainabe change emerged from the experience of one acute trust that successfuy contained a dramatic rise in the number of cases of Costridium difficie, a heath care-associated infection. Success endured ong after the short-term crisis management phase, suggesting an approach that other trusts facing simiar probems coud usefuy adapt. xii NIHR Journas Library

15 DOI: /hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Managing change in wicked situations, visua toos such as end-state mapping, mess mapping and mutieve future panning can be hepfu in understanding the dimensions of a probem, identifying and potentiay reconciing competing perspectives and deveoping action pans. High-reiabiity organisation concepts have seen imited appication in heath-care settings. Going we beyond the concept of safety cuture, this shoud be an important topic for the deveopment of practice, and of evauation research. Contributions Contradicting traditiona stereotypes and contemporary media imagery, midde management contributions to cinica and organisationa outcomes are mutifaceted and incude maintaining day-to-day performance, firefighting, ensuring a focus on the patient experience, transating ideas into working initiatives, identifying and seing new ideas, faciitating change, troubeshooting, everaging targets to improve performance, process and pathway redesign, deveoping infrastructure [information technoogy (IT), equipment, physica equipment], deveoping others and managing externa partnerships. Midde managers often find themseves in a ow-trust ow-autonomy environment in which the abiity to make independent decisions concerning the effective running of their service is constrained by the perceived unnecessary interference of senior coeagues. The attributes of an enabing environment for midde management contributions are common sense: good communications, timey information, streamined governance, autonomy to innovate and take risks, information sharing not constrained by sio working, interprofessiona respect, supportive support services, teamwork, adequate resources. These characteristics may indeed make sense but they do not appear to be common. Many of the probems facing midde managers are wicked probems : understood differenty by different stakehoders; not amenabe to rationa, inear, reductionist probem-soving methods; with no right or wrong answers; and with ony better or worse soutions. Exampes (arising in this project) incude winter contingency ward panning, managing compex discharges, and staff performance management. The manageria contribution in such contexts is key, as medica staff training in particuar emphasises diagnostic and probem-soving approaches that are not appicabe to wicked probems. Whereas current commentary emphasises radica transformationa change, this project identified a methodoogy, sweat the sma stuff, demonstrating how a deiberate focus on sma probems, with direct staff ownership, and fixing these rapidy, coud generate significant gains for patients, staff and the organisation as a whoe at minima cost, aying the foundations for coaborative approaches to tacking arger-scae changes. This approach won an innovation award in the trust where it was first appied, where its appication was extended successfuy to other services, and where training for other staff in this approach was introduced. Actions to buid and maintain an enabing environment to support management contributions incude suggestions for individua capabiities and behaviours, divisiona practices, corporate issues and recommendations for the top team such as do not medde in operations, avoid panic of the week and isten to midde managers who know more about operationa issues. Steps such as these coud potentiay generate significant gains, and most are cost neutra. In a context characterised by conficting and changing institutiona priorities, increasing workoads, diminishing resources and extreme jobs, management capabiities at a premium incude poitica skis (infuencing and negotiating), resiience, deveoping interprofessiona coaboration, performance management, financia skis and addressing wicked probems. One feature strengthening the management contribution concerns the power of cinica medica manageria coaboration, aso described as paired earning. This can be a ow-cost or cost-neutra approach to innovative service improvement. One feature weakening the management contribution concerns the sio working that is reinforced by the service-ine management structures which foundation trusts in particuar have been encouraged to adopt. Queen's Printer and Controer of HMSO This work was produced by Buchanan et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xiii

16 SCIENTIFIC SUMMARY Concusions and research priorities 1. Management capacity. This study highights the significance of the concept of management capacity and one research priority woud be to deveop better theoretica and practica understanding of the factors that infuence that capacity. This issue is significant for at east three reasons. First, the widey distributed management function in acute trusts is dominated by untrained, and in some cases reuctant, cinica hybrids with part-time manageria responsibiities, often responsibe for arge numbers of staff and mutimiion pound budgets. Second, acute trust management agendas are extensive, and mutioaded, with a wide range of strategic issues, a of which are aways priorities, pacing increasing demands on the management function. Third, despite financia and other resource pressures, the service is expected to be creative, innovative and commerciay oriented, improving simutaneousy the cost-effectiveness, quaity and safety of patient care. These issues present management chaenges that cinica staff are often unwiing or unabe to address working on their own. At a time of financia constraint, how can management capacity be assessed and strengthened? 2. Extreme jobs. A second research priority concerns the nature and incidence of extreme jobs among the heath-care management popuation, and the individua and organisationa impications of such roes. It appears that some managers find work of this nature chaenging and rewarding, to the extent that they have crafted this roe deiberatey, and for them the extreme nature of the roe may not be probematic. However, the existence of such roes may aso be symptomatic of inadequate resourcing and training, and sustaining an extreme job can have adverse impications for work ife baance and stress, and may increase the incidence of errors. For hybrids in extreme jobs, this profie coud potentiay compromise patient safety (athough this project generated no evidence for that outcome). How coud such roes be redesigned, to make them ess extreme, or positivey extreme, and/or what forms of support can be deveoped for extreme job hoders, perhaps incuding resiience training? 3. Service-ine sios. A third priority concerns understanding the advantages and drawbacks of the service-ine management structures that foundation trusts have been encouraged to adopt. Service-ine management invoves restructuring a hospita around cinica business units, each operating as a business within a business. The advantages of this approach incude reative service autonomy, coser cinica engagement in service panning, strategy and improvement, and greater transparency with regard to income and costs. Evidence from this study suggests, however, that these structures entrench a sio mentaity, generate tension and hostiity between divisions, reduce the sharing of information and the exchange of good practice and aso reduce cross-divisiona understanding (a probem for duty ead nurses in particuar). What is the baance of gains and disadvantages in service-ine management structures, and how can the disadvantages be overcome whie the gains are sustained? 4. Incident investigation. A fourth priority concerns the deveopment of methods to understand the causes of serious incidents, and to ink these with appropriate change agendas. Root cause and timeine anayses are widey used and vauabe toos for identifying the cause or causes of an incident, eading to recommendations for action to prevent or reduce the probabiity of a recurrence. These methods, however, tend to focus on what can be earned from an individua incident, concentrate on proxima causes and precude those invoved in an incident and its aftermath from a roe in determining the changes that shoud be made. It may aso be usefu to consider what can be earned from incidents ike this and to incude those who were impicated in the investigation and change panning, exporing systemic causes and other contributory factors through mess mapping and reated visua toos. This perspective woud be consistent with the system-theoretic accident modes now used in other sectors. What woud be the advantages and imitations of this systemic approach to incident investigation and change? 5. High reiabiity. Based on studies of aircraft carriers and nucear power instaations, the quaities of high-reiabiity organisations incude a mindfu preoccupation with faiure, reuctance to simpify and deference to expertise, which may, depending on circumstances, reside with junior staff who are cosest to the fow of events. There have been reports of attempts to deveop pockets of high reiabiity in heath-care settings. With the continuing priority attached to improving the quaity and safety of patient care, whie reducing costs and increasing productivity, it woud be vauabe to consider the more systematic appication and evauation of high-reiabiity methods taiored in particuar to acute heath-care settings. xiv NIHR Journas Library

17 DOI: /hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Funding The Nationa Institute for Heath Research Heath Services and Deivery Research programme. Queen's Printer and Controer of HMSO This work was produced by Buchanan et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xv

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19 DOI: /hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Chapter 1 Aims, background and methods Note: the missing front ine The subtite of this project concerns the reaities of midde and front-ine management work. The probems of defining midde management, in any sector, and the ambiguities surrounding the ocation of front-ine hospita managers, ed to us drop and front-ine from this report. Roe tites (ward sister, divisiona nurse, operations manager), athough not aways accurate or consistent, offer a better guide to the nature of the work and responsibiities of post hoders than midde or front-ine designations Things can ony get different You' hear peope say management in inverted commas. And I' say, but you a manage. I think that there's aways been quite a hierarchy in the NHS. And I do not beieve we've done as much as we can to break that down. I want everyone to take accountabiity and responsibiity. Modern matron, Netherby hospita How do hospita managers in the NHS hande the demands of a constanty changing service? How do managers affect the quaity of patient care and cinica outcomes? Patient safety is a nationa priority, but changing working practices foowing serious incidents can be probematic. Why? We know surprisingy itte about the work experience, practices and attitudes of hospita managers, who are key to impementing oca strategy and nationa initiatives. However, when things go wrong, this is the group that often takes the bame. This study seeks to buid on what we know about management, change and eadership, and reate this to current trends. This chapter describes the research questions and aims of this study, expains the background to the project and provides an overview of the research process and methods. This project began in By 2012, however, the service had changed in a number of significant ways. Two events in particuar had an impact on acute hospita management roes during this period. Economic crisis The first of these events was the coapse of the investment bank Lehman Brothers, which fied for Chapter 11 bankruptcy protection in America on 15 September With debts of over US$600B, this was the argest corporate faiure in American history, triggering a goba financia crisis. This in turn ed to massive government spending around the word to recapitaise other banks that were cose to coapse because of their exposure to Lehman's debts. In the UK, financia support for the banking sector increased UK pubic sector net debt to 845B by the end of 2009, prompting action to reduce government spending. Government poicy was to protect the NHS budget (> 100B a year). Nevertheess, cost infation in the heath service is historicay higher than genera infation, and fat funding or sma rises amounting to rea decreases in annua NHS spending can generate deficits for individua provider organisations. In 2010 the chief executive of the NHS, Sir David Nichoson, thus set the service the target of generating 20B of efficiency savings (one-fifth of annua spending) by Known as the Nichoson chaenge or Queen's Printer and Controer of HMSO This work was produced by Buchanan et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 1

20 AIMS, BACKGROUND AND METHODS the NHS recession, a heath-care providers had to consider radica cost improvement programmes (CIPs) whie maintaining the eve, quaity and safety of services. New government The second event was the eection of a Conservative Libera Democrat coaition government foowing the genera eection in May The new Secretary of State for Heath pubished his first White Paper in Juy This set out proposas to aboish primary care trusts (PCTs) and strategic heath authorities, give most of the NHS budget to cinica commissioning groups and create a Nationa Commissioning Board. Trusts were aso expected to achieve at east 3.5% cost improvements annuay over 3 5 years whie improving quaity of care. The Secretary of State aso proposed a 45% cut in the management costs of the service by Government ministers depicted heath-care managers as costy, pen-pushing bureaucrats, and the service was now to be run by cinica staff: genera practitioners, hospita doctors, and nurses. These and other structura and reguatory changes were consoidated in a Heath and Socia Care Bi introduced to Pariament in January The engthiest piece of egisation in British history, the bi's provisions were controversia. The uncertainties surrounding these proposas, how they woud operate in practice and the impications for funding created a chaenging management agenda. As one participant in this project observed: Netherby is a 250 miion hospita. Over the next three years, we're ooking at infated costs and defated income. If we do nothing, in three years time, we wi be osing up to 30 miion a year, so we need to do something now. We have a transformation steering group whose remit is to design a programme to prevent the trust running up an annua 30 miion oss. We want to avoid sash and burn, but we do need to ose staff and cut management ayers. This means big change. Director, Netherby hospita Budget cuts, new structures, tighter reguation, fresh priorities, negative stereotyping some participants in this study said that they had seen it a before. The NHS, which ceebrated its 60th anniversary in 2008, has been subject to changes of this nature throughout its history. But for the majority of participants, this was new; one manager observed, it fees different this time. The scope of the structura and reguatory changes, the severity and pace of funding cuts, the need to improve quaity and safety, and the job insecurities were unprecedented. Foowing Lehman's coapse and the shift in government poicy, for heath-care managers it was no onger business as usua. The acute hospita mode was chaenged with strategies for moving care into the community, focusing on prevention (acoho abuse, obesity) and on sef-management of ong-term conditions (asthma, diabetes). From 2011, changes to tariffs meant that hospitas woud no onger be remunerated in fu for increases in emergency department attendances, and woud be penaised for (among other breaches) emergency readmissions within 30 days. Management confidence in the abiity of the service and individua provider trusts to deiver the necessary savings was ow. 2 The NHS was thus passing through a further period of rapid and radica change during the ife of this project. The context in which management work is carried out is crucia. The management impications of the changing institutiona context are expored in Chapter 3. The oca organisationa contexts of the trusts participating in this project are discussed in Chapter 4. As institutiona and organisationa contexts change, management roes change too. As the chief executive of The King's Fund observed, things can ony get different (p. 14). 3 2 NIHR Journas Library

21 DOI: /hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Research questions Interviewer: What outputs woud you ike to see from this project? Respondent: I want to understand what we can do to support and hep those in increasingy chaenging roes, because we need to get it right. Otherwise, they wi do it bady or won't do it. I want to gain a better understanding of their motivation, so that we can hep provide meaningfu careers. Senior executive, Greenhi hospita This project addressed three sets of questions: 1. Reaities: What are the pressures and demands facing midde managers in heath care? What are the impications of these trends? 2. Changes: What roes do midde managers pay in impementing changes? How are changes arising from serious incidents impemented, and how can this process be improved? 3. Contributions: How does management practice affect cinica and organisationa outcomes? What factors infuence management contributions to performance? How can the components of an enabing environment for management work be assembed and sustained? Reaities We can caim some understanding of the nature of genera management roes, 4 the reaities of management work, 5 rewards and pains 6 and how managers spend their time. 7 Is that knowedge reevant to heath care today? This project sought to understand how current pressures have affected the reaities of midde management work in acute settings. Convention has managers running things as they are whie eaders drive change. But managers at a eves in the NHS coud be excused a cynica response to that distinction, having impemented a series of major changes affecting a aspects of the service cuture, structures, priorities, governance, working practices and more. Changes There is a widespread perception that the management of change in heath care is especiay probematic. 8 This has ed to a renewed emphasis on medica engagement in eadership and change. 9,10 Recent evidence suggests, however, that many radica changes are impemented, not by sma groups of senior managers and doctors, but by distributed groups of midde managers and others, incuding cinica staff. 11 Severa studies undermine the distinction between eaders who drive change and managers who maintain order, emphasising midde management roes in strategy, and in change under the radar The deveopment of distributed change eadership, based on the spontaneous concertive action of staff at a eves, is evident in heath care. 15,16 Cark et a. 17 note that Enhanced cinica engagement shoud work towards a mode of diffused eadership, where infuence is exercised across a compex set of reationships, systems and cutures (p. 32, itaics added for emphasis). Change is thus a centra aspect of midde management work. 18,19 Foowing serious incidents, the recommendations from investigations are sometimes adopted rapidy. However, despite efforts to earn the essons, these recommendations often ead to itte or no action. 20 Noting that the pace of change in improving patient safety had been sow, Donadson 21 cited the distinction between passive earning (identifying essons) and active earning (impementing changes), noting that the atter does not foow automaticay. This project thus expored the processes of change foowing serious incidents, to identify the conditions that respectivey bock and promote change in such contexts. Contributions One research tradition has sought to understand what managers do. 4,22 Another ine of research concerns the contributions that midde managers make to cinica and wider organisationa outcomes. This project sought to identify the conditions that enabe, support and strengthen those contributions. Evidence suggests a systemic ink between management practices and outcomes Management competencies are key, but organisationa context is aso crucia in determining receptiveness, 26 setting priorities and incentives, focusing Queen's Printer and Controer of HMSO This work was produced by Buchanan et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 3

22 AIMS, BACKGROUND AND METHODS attention and energy and estabishing an environment that either enabes or stifes service improvement. What does an enabing environment ook ike? How can the components of an enabing environment be assembed and sustained? One of the outcomes of this project (see Chapter 7) is a contributions-based mode of management work. Why midde management? The ward eaders sisters and charge nurses make or break the hospita's reputation. We have over fifty wards on two sites. Each has a team of twenty to thirty staff operating 24/7. It's where the costs arise, and where patients and visitors make judgements about standards, depending on staff approach and discipine. That's where the key business of patient care is. Senior executive, Greenhi hospita The NHS has since the mid-1980s focused attention on chief executives and trust boards. One manifestation of this was the Leadership Quaities Framework. 27 When it was first pubished, the principa investigator for the current project was working with a hospita in the Midands. The human resources director was running management deveopment sessions for new cinica directors and business managers a group of senior midde managers. She teephoned the Leadership Centre (part of the NHS Modernisation Agency) and requested 20 copies. She was asked about the use to which these woud be put. When she expained, she was tod that copies coud not be provided. Why not? Because the framework was designed for board-eve directors and not for ess senior staff. This anecdote is symptomatic of what appear to be deep-rooted attitudes towards eadership and management in the NHS. Since 2009 there has been a Nationa Leadership Counci. There was no Nationa Management Counci. There was an eite top eaders programme for those in roes deemed to be business critica. There was no top managers programme. The NHS had deveoped severa eadership competency frameworks. There were no management competency frameworks. An NHS Leadership Academy was aunched in November There was no Management Academy. The updated version of the Leadership Quaities Framework 28 does suggest that the framework appies to staff at a eves except for two of the seven domains, creating the vision and impementing the strategy, which are the preserve of a reativey sma group of peope who hod designated positiona roes, and are required to act as eaders in forma hierarchica positions. These two domains focus more on the contribution of individua eaders rather than the genera eadership process (p. 8). If this genera eadership process means midde managers, then this impicit division of eadership abour ignores two decades of compeing research evidence. 29,30 One consequence of the focus on senior eadership is that ess is known about the roes, experiences, contributions and motives of midde managers. 31 The presumption that their contributions are ess business critica has passed unchaenged. The Service Deivery and Organisation (SDO) research programme had funded previous studies on eadership, organisation cutures, performance management and service reconfiguration. Those studies, however, did not expore directy the work of midde managers. There was, therefore, a pressing need for research into the chaenges facing management in heath care and this was recognised as a priority theme for research. 32 Have conditions changed so dramaticay since 2007 as to render the findings from this project obsoete? On the contrary. The impact of institutiona and organisationa context remains centra to our understanding of management roes and contributions. For acute hospitas, change agendas are compex and chaenging, and midde managers are key to impementation. Athough other issues have surfaced and generated additiona research questions, the chaenges that the NHS has faced since 2007, and wi face from 2012 onwards, have ony reinforced the importance of this theme. 4 NIHR Journas Library

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