Fit to Lead: the experience of the Italian Association of Medical Managers

EHMA Annual Conference 2010 Managing Radical Change in Health: Quality, Efficiency, Equity Special Interest Group (SIG) Health workforce management Lahti, Finland 30 July 2010 Fit to Lead: the experience of the Italian Association of Medical Managers Lazzari A; de Belvis AG; Ricciardi W

Once upon a time Rome, 28th November 2006 Birthday of the Italian Association of Medical Managers (SIMM) An enthusiastic group of forty doctors involved and interested in management for years, representing the different regional needs of the country, decided to make quality improvement in health care management an effective reality in the Italian context too.

I primi 3 anni di MISSION Promote, develop and strengthen the role, the function and the competences of medical management in the Italian healthcare context Iniziative of Prof. Walter Ricciardi and 40 enthusiastic doctors Supported by Prof. Jenny Simpson and BAMM expertise, in collaboration with the American College of Physicians Executives No profit organisation Membership growth Leading inspired, skilled, creative and energised leaders, every day SIMM Strategic Plan 2008-2010

Why healthcare systems need medical managers Doctor managers have distinct advantages Jenny Simpson, Richard Smith BMJ 1997; 314:1636 (7 June)

Sir Luke Fildes: The doctor, 1861

The Clinician was the driving force in the 20th Century, the patient will be the driving force in the 21st century Sir M. Gray, 2009

DIFFERENT ACTORS AND PERSPECTIVES Politicians? + $$ Risultati Soddisfazione cittadini RE-ELECTION Professionals ASAP GOOD COMFORTABLE CONSISTANT KEEP QUITE!!! + HUMAN RESOURCES + FINANCIAL AND TANGIBLE RESOURCES Medical Boards S.O.S.! Chief Executives SAVE! Elections Citizens, Patients (Costa J in Sunol R, 1990)

The most obvious cause of doctors' unhappiness is that they feel overworked and undersupported. They hear politicians make extravagant promises but then must explain to patients why the health service cannot deliver what is promised. Why doctors are so unhappy? Doctors and patients: redrafting a bogus contract Smith R BMJ 1997; 314:1636 (7 June)

Doctors in trench?

Rely on citizens Develop systems, not institutions Develop the culture Love the technology Manage knowledge as though it were money Pencheon et al, 2006

The grass is always greener? It s well known than Italians tend to be a bit xenophile they always look at foreign experiences and practices Italians are even often ready to manage without any hesitation or distintion receipts and solutions for our problems edited by British gourmet I must confess that I m a bit snob and my personal belief was that (...) the grass is not always greener (...). Right then, the more I read Management for Doctors [Simpson J, Smith R, 1995] the more I realized (a bit disappointed) that English healthcare have a lot to teach Cesare Fassari Introduction to Simpson J, Smith R (1998)

Medical managers training in the British NHS Chief Executive Chief Executive Modello 1 Chief Executive Medical Director ClinicalDirector Primary Care Trust Lead (PCT) PCT Medical Director PEC Chair (member of board) Medical Director Clinical Directors PEC Member Deputy Medical Director Lead consultant GP Modello 2 Consultant GP Training Scheme Chief Executive Specialist Registrar Training (SpR) GP registrar (SpR) Medical Director Clinical Directors Senior House Office Pre-Registration House Officer Clinical Governance AMD Medical Staffing AMD External Relationship s AMD IT and information AMD Risk management & complaints AMD Medical Student Fig. 1 Academical Educational/Training Pathway to medical management Source: personal re-elaboration from BAMM documents, edited on BAMM Deputy of Strategy guidelines Fig. 2 Models of Deputy/Associate Medical Director Source: BAMM Making Sense: a career structure for medical doctors 2004

It has been a long, long journey From: Until systems of management and clinical process are totally aligned, the NHS will never be managed effectively To: Sir Roy Griffiths, October 1983 Every doctor licensed to practice in the UK will, by law, relate (account) to a responsible officer, who will review their performance and make a recommendation to the GMC as to their fitness to practice Draft Guidance for Responsible Officers, January 2010

Our healthcare context P Diversity in the European region Health professionals/100.000 population, 2002 Source: WHO HFA database, 2007 The essential trust between physicians and citizens is under threat in Italy

Legislative framework 1938 Decree n.1631 Medical Management function in hospitals 1978 Law n.833 Establishment of the National Health Service (SSN) Art. 32 National Constitution Right of health for all Creation of USLs on the UK district health authorities model in terms of functions and reference populations 1992-1993 Legislative decree n.502/92 and n.517/93 Introduction of competition in the health care sector, adopting the internal market solution. Process of regional devolution of political and financial accountability was launched Freedom of choice to patients CPD for healthcare professionals 1997-2000 Series of fiscal reforms aimed to contain the raised costs and the inefficiency in the allocation of resources, devolved financial autonomy and responsibility to regions (see Law No. 59/1997 Bassanini Law ; Legislative Decree No. 446/1997 Visco Decree 1998-2000 First National Health Plan 1999 Legislative decree N. 229 Institutional accreditation of public and private providers, based on assessing the quality of their infrastructure and human resources. Reinforcing essential requirements for education and training as medical managers 2001 Reform of Constitution strenghtening devolution (Donatini et al 2001, Primicerio 2003)

Medical Degree for Over 46% of Italian CEO* Fig. 2 Prevalenza (%) delle Specializzazioni tra i medici, per area Italian Top Managers profile: Figura 1. Piramide delle età dei Direttori Generali di ASL e AO italiane (VA, su 298 soggetti censiti a livello nazionale) Fonte: De Belvis et al, 2008 male, between 50 and 60 years old (Fig. 1) graduated before 1977 majority of Doctors mostly specialized in the services area (Fig. 2) majority of them specialist in public health over 70% former top managers at apical levels * CEOs LHUs, Ospedaliere e delle Agenzie regionali sanitarie.

Doing things cheaper Efficiency Doing things right Doing things better Quality improvement Doing the right things right Doing the right things increasing effectiveness 70 80 90 2000

On the yellow-brick road** (forthcoming challenges) Sustaining Change The management of culture is one of the responsibilities of the leader. Sir M. Gray, 2009 There is nothing more difficult to execute, nor more dubious of success, nor more dangerous to introduce a new order to things; for he who introduces it has all those who profit from the old order as his enemies; and he has only lukewarm allies in all those who might profit from the new. This lukewarmness partly stems from fear of their adversaries, who have the law on their side, and partly from the skepticism of men, who do not truly believe in new things unless they have personal experience in them." Niccolò Machiavelli

Make it happen Annual Conference with International Scientific Committee Skills Factory - Masterclass in clinical management, medical leadership and communication Daily seminars/workshops focused on specific items in collaboration with strategic partners from non-healthcare sector SIMM JmL programme for doctors in training Newsletter Medici Manager journal Self assessment tool Web site and login contents Facebook Linked-in Network of proactive top professionals at regional, national and international level (see also partnerships)

The first 3 years (and half!) of MEMBERSHIP GROWTH 350 344 300 300 250 248 200 150 163 100 50 0 2007 2008 2009 2010 *Updated 11.06.2010.

Regional Distribution and Branches Members per Region Lombardia Piemonte e Valle D'Aosta Emilia Romagna FVG, Veneto, Prov. Trento Campania Liguria Lazio Veneto 20 Umbria 1 Trentino Alto Adige 19 Toscana 9 Svizzera Sicilia 1 3 Sardegna Puglia 17 18 Piemonte & Valle D'Aosta 64 Molise 0 Marche 8 Lombardia Liguria 16 13 Lazio 29 Friuli Venezia Giulia Emilia Romagna 12 10 Campania 36 Calabria 0 Basilicata 31 Abruzzo 2 0 10 20 30 40 50 60 70

Seminars and Workshops Presentations and Panels on a specific item at the top of the healthcare agenda SIMM action as facilitator among the different stakeholders

Masterclass in clinical management, medical leadership and communication Skills Factory 2006 Start up event: from Uk to Italy 2007 Pilot events all over Italy 2008 Training event for trainers in Uk 2010 Ready to launch the complete training pathway

Masterclass in clinical management, medical leadership and communication Skills Factory Classes: 15-20 people (never more than 25) Goal: strengthening doctors awareness, ability and trust in managerial skills in order to make them fit to lead Methods: Indoor training, case studies, role play, fitness sessions, action learning with the Creative Challenge Both doctors and non doctors trainers

Feedback il clima assolutamente informale che ci ha consentito di sentirci più vicini ai colleghi con cui condividiamo problemi quotidiani della stessa natura sono rimasto colpito dall ottima alternanza di concetti teorici ed esercitazioni pratiche, dall utilizzo di metafore, filmati e testimonianze che spesso hanno stimolato momenti di discussione davvero interessanti penso sia un valido momento per imparare a lavorare in team, prendere coscienza della capacità di mettere in pratica quanto appreso nel tempo ed uno stimolo a proporre idee nuove per la risoluzione del problema 26

SIMM Training Pathway Open SIMM, Open Mind Model

Self assessment standards Score Sheet Enter your score for each standard in the grids on the following pages Communication D C B A 1.1 Communicating Information 1.2 Listening 1.3 Giving Feedback 1.4 Influencing 1.5 Negotiating 1.6 Managing Effective Meetings 1.7 Communication of Untoward Incidents 1.8 Working with the Media 1.9 Liaison & Co-Ordination with other Organisations 1.10 Giving Effective Presentations Managing & Developing People D C B A 2.1 Appraisal 2.2 Managing & Developing the Performance of People 2.3 Supervision 2.4 Managing Difficult Colleagues & Situations 2.5 Managing Change 2.6 Team Working & Development 2.7 Job or Role Planning 2.8 Counselling, Coaching & Mentoring 2.9 Workforce Planning 2.10 Teaching, Training, Learning & Development 2.11 Instilling a Common Purpose Managing & Developing the Business D C B A 3.1 Financial Awareness 3.2 Controlling & Monitoring the Business 3.3 Operational & Performance Management & Development 3.4 Developing & Communicating a Strat. Vision/Common Purp. 3.5 Budgets 3.6 Business Planning 3.7 Strategic Planning 3.8 Information Management & Technology 3.9 Health & Safety 3.10 Project Management Managing & Developing Self D C B A 4.1 Maintaining & Developing Professional Competence 4.2 Personal Effectiveness 4.3 Managing Time & Setting Priorities 4.4 Personal Development 4.5 Leadership Styles 4.6 Managing Stress Self development reflective tool

Beyond the scalpel, a manager mind Sole 24Ore Sanità Charismatic Leadership and managerial culture Panorama della Sanità Credit crunch calls for medical managers Doctornews33 Involving doctors, bettering services and saving money: mission possible? Experts: with the crisis, medical manager for better healthcare and savings FIMP Federazione Italiana Medici Pediatri 200 partecipants (medical and clinical directors, istitutional and accademical representatives and stakeholders) with national and international speakers. measured themselves

Ricciardi, 2010

v PERFORMANCE ACCOUNTABILITY E GESTIONE DELLE PERFORMANCE Country x Regular Sistematic transparent Comprehensive balanced Deep analysis Linked to accountability Linked to management performance UK Yes Yes Yes Yes Yes NL Yes Yes Yes Yes Yes S Yes Yes Yes Yes Yes P Yes Yes Yes /NO Yes NO I?????

Shift Happens. Tools for changing healthcare Rome, 16 November 2009 in the 21 century

The Journal Medici Manager

First issue: October 2009 Leading inspired, skilled, creative and energised leaders, every day 35

Updated Version 2010 Leading inspired, skilled, creative and energised leaders, every day 36

Partnerships

References Anessi Pessina E., Cantù E. (a cura di), L'aziendalizzazione della sanità in Italia. Rapporto OASI 2006, Milano, Egea, 2006 BAMM (2004) Making Sense. Acareer structure for medical management Stockport:BAMM Barbieri F, Patti F (2008) Asl e ospedali:ecco chi comanda Il Sole 24 Ore 7 Gennaio 2008. N.6 De Belvis AG, Lazzari A, Avolio M, Biasco A, Ricciardi W (2008) Indagine nazionale sul profilo e il percorso formativoprofessionale dei Direttori Generali delle Aziende Sanitarie Locali ed Ospedaliere Italiane Medici Manager 1:2008 Fassari C in Simpson J Management Medico. Guida pratica alla gestione aziendale (1998) Esis: Roma Lazzari A, De Micco F, de Belvis AG, Ricciardi W (2008) La sanita`costa. Ma quanto paga? Indagine sulla condizione retributiva dei medici in Italia e nei paesi OCSE Medici Manager, 2:2008 Le Fanu, J 2005 Ascesa e declino della medicina moderna Milano:Vita e Pensiero Morosini, Perraro. Enciclopedia della gestione della qualità in sanità, 2001, Centro Scientifico Editore Peck C, McCall M, McLaren B, Rotem T (2000) Continuing medical education and continuing professional development: international comparisons BMJ, 320:432-435 Pencheon D, Melzer D, Gray M, Guest C. Oxford Handbook of public health practice. Oxford University Press, 2006 Simpson J, Smith R 1997 Why healthcare systems need medical managers. Doctor managers have distinct advantages BMJ 1997; 314: 1636 Smith R (2003) What doctors and managers can learn from each other. A lot BMJ 326:610-611 Simini B Italian doctors stand their ground The Lancet, Volume 354, Issue 9177, 7 August 1999, Page 495 http://www.sciencedirect.com/science Why are doctors so unhappy? BMJ 2001;322(7294):1073 available on line: http://www.bmj.com/cgi/content/extract/322/7294/1073 WHO (2000) The World Health Report 2000 Genova:WHO WHO Regional Office for Europe, 2007 available on line http://www.who.int/about/regions/euro/en/index.html WHO (2009) Health in times of global economic crisis: implications for the WHO European region WHO The European health report 2009: Health and health systems available on line: http://www.euro.who.int/ data/assets/pdf_file/0009/82386/e93103.pdf

Kiitos Enjoy Finland! agnese.lazzari@medicimanager.it