Managing doctors and nurses: do we know what works?

Transcription

1 Managing doctors and nurses: do we know what works? Orvill Adams and Leanne Idzerda Orvill Adams & Associates Incorporated

2 Pressures for change Health sector reform change in health care financing decentralization emphasis on primary care emphasis on health promotion and disease prevention Greater accountability Improved performance Greater efficiency Improved quality Improved access and equity 2

3 Trends in demand for management Management identified as a key strategy in Poverty Reduction Strategy Papers Donors assisting countries by providing technical support for the strengthening of management Emphasis on the development of support systems for management Evidence that improved management is a key factor in system and organizational performance 3

4 Key issues in management Call for doctors to play a greater role in management and leadership In the majority of countries the senior managers are clinicians with little training in management techniques There is still a view among some doctors that the profession should not be involved in management and instead should protect their autonomy Physician managers are often not rewarded for management and do not have good career opportunities Nurses have a role to play as front line managers Imbalance of power between doctors and nurses 4

5 Relationships in management: Tensions Cultures Medical and Managerial Clinicians and Physicians in Management Physicians in Management and Administration Doctors and Nurses Command Team Doctors and informed patients 5

6 Conflicting cultures Medical Culture: Autonomous decision making Reactive approach to problem solving Focus on individuals within the context of their biological, psychosocial and sociological environments Managerial Culture: More collaborative and attempts to be proactive about problem solving A broad focus on needs of the institution or overall health care system Responsible for maximizing results across multiple stakeholders (McAlearney et. al. 2005) 6

7 Management Process An ongoing series of activities concerned with strategic goal setting, operational decision making and resource allocation (Buchanan, 1997) 7

8 The doctor as manager Four key competencies: 1. To participate in activities and contribute to the effectiveness of their health care organization and system; 2. To manage their practice and careers effectively; 3. To allocate finite health care resources appropriately; 4. To participate in administrative and leadership roles. (Stergiopoulos et. al. 2009) 8

9 Content of management Management of medical staff relations Efficiency practices Quality management Legal and regulatory issues Liaison functions Cost management Decision making in uncertain situations Clinical medicine Organizational issues (Birrer, 2003) 9

10 Models of Physician Management Medical Director Consultant Manager Consultant Coordinator Clinical Triumvirate Clinical Service Divisional Directorate Direct Access Directorate 10

11 Comparative management practice Literature suggests that in the UK and Canada the majority of physician managers work part-time up to 50% of their time in Canada Clinical Directorate in UK vs. Dyad in Canada (a doctor and a nurse or paramedic manager) Dyad is less hierarchical works well in times of change Doctors in the UK have a less collegial relationship with their professional colleagues Doctors in both countries have accepted that performance management and quality of care are important aspects of their role (Fitzgerald and Dufour, 2008) 11

12 Developing skills and competencies Modalities of training and education One on one mentoring Workshops Seminars Community service experiences Masters degree Internal and external programs Trend towards internal programs Internal programs reflect the values and culture of the organization 12

13 Training and education programs Certificate of Medical Management Executive Graduate Certificate Master of Medical Management Master of Administrative Medicine Health Executive MBA (Schwartz et. al. 2000) 13

14 Management capacity building Successful programs: Self-assess and critically analyze the context in which change is planned Simultaneously address organizational structures, systems and processes together with training of individuals and teams Simultaneously build new systems while learning new roles and competencies Emphasize practical application of knowledge for building self-reliance at all levels of the health system 14

15 Factors affecting management Insufficient coordination among managers Inadequate support of senior management Lack of timely information Reward for mangers Shortage of appropriately trained physician and nurse managers Migration of nurse managers 15

16 Role of Nurse Managers Nursing management aims to ensure that a vibrant and skilled nursing workforce can flourish and respond effectively to the diversity needs of health care recipients and the general public Nurse managers are directly responsible for managing nursing services Shortages of qualified nurse managers 16

17 Strengthening nurse manager satisfaction Role development support Compensation systems Communication systems Education systems Organizational climate Providing nurse managers with autonomy over decisions that work at the unit level Building relationships, sharing decision making, sharing knowledge Building supportive teams (Parsons and Stonestreet 2003) 17

18 Lessons 1. Management is not about giving orders, but rather about finding areas of agreement so that you can move forward 2. They must understand that managerial and professional accountability are different 3. Responsibility and authority must be commensurate with each other and they must be delegated as much as possible 4. Scheduling and keeping regular meetings with managers is important 5. Involving nurse managers in planning and decision making for the entire nursing organization provides them with executive role modeling 6. Need for work/life balance Smith et. al

19 Principles of Management Selflessness Integrity Objectivity Accountability Openness Honesty Leadership General Medical Council, UK (approved 2005) 19

20 Competencies and standards that define a good manager (1). 1. Lead a team effectively 2. Identify and set objectives 3. Communicate clearly 4. Manage resources and work to achieve maximum benefits, both day to day and in the longer term 5. Make sound decisions in difficult situations 6. Know when to seek help and do so when appropriate General Medical Council, UK (approved 2005) 20

21 Competencies and standards that define a good manager (2) 7. Offer help to those you manage when they need it 8. Demonstrate leadership qualities through your own example 9. Manage projects 10. Manage change 11. Delegate appropriately to empower others to improve services and develop skills of the people you manage without giving up your own responsibilities 12. Consider and act upon constructive feedback from colleagues General Medical Council, UK (approved 2005) 21

22 References Birrer, R. B Becoming a physician executive. to be effective leaders, clinicians must first adopt a new mind-set. Health Progress 84, (1) (57; Jan-Feb): Buchanan, D., S. Jordan, D. Preston, and A. Smith Doctor in the process. the engagement of clinical directors in hospital management. Journal of Management in Medicine 11, (2-3): Fitzgerald, L., and Y. Dufour Clinical management as boundary management. A comparative analysis of canadian and UK health-care institutions. Journal of Management in Medicine 12, (4-5). General Medical Council Management for Doctors. Guidance Document. McAlearney, A. S., D. Fisher, K. Heiser, D. Robbins, and K. Kelleher Developing effective physician leaders: Changing cultures and transforming organizations. Hospital Topics 83, (2): Parsons and Stonestreet Factors that contribute to nurse retention. Nurs Econ.;21(3). Schwartz, R. W., Pogge, C., Gillis, S., Holsinger, J Academic Medicine, Vol. 75. No 2. Smith, R., Grabham, A. Chantler, C. A conversation among, BMJ. Volume 298, 1989 Stergiopoulos, V., Maggi, J., Sockalingam, S., Teaching the Physician Manager Role to Psychiatric Residents: Development and implementation of a pilot curriculum. Academic Psychiatry 33 (2) 22