HEALTH SERVICES AND DELIVERY RESEARCH

HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 1 ISSUE 4 JUNE 2013 ISSN 2050-4349 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 10.3310/hsdr01040

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: 10.3310/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).

Heath Services and Deivery Research ISSN 2050-4349 (Print) ISSN 2050-4357 (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) (www.pubicationethics.org/). Editoria contact: nihredit@southampton.ac.uk The fu HS&DR archive is freey avaiabe to view onine at www.journasibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: www.journasibrary.nihr.ac.uk 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 2012. 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: www.netscc.ac.uk/hsdr/ 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 2009. The fina report began editoria review in Juy 2012 and was accepted for pubication in January 2013. 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 2013. 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 (www.journasibrary.nihr.ac.uk), produced by Prepress Projects Ltd, Perth, Scotand (www.prepress-projects.co.uk).

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: www.journasibrary.nihr.ac.uk/about/editors Editoria contact: nihredit@southampton.ac.uk NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2013. 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

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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 1 1 3 4 5 11 11 13 17 17 21 21 22 28 31 31 31 35 36 37 41 41 42 43 44 46 48 50 56 59 59 61 63 67 71 73 76 Queen's Printer and Controer of HMSO 2013. 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

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 81 81 82 84 90 95 98 101 103 117 137 159 213 223 227 229 241 viii NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2013. 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

DOI: 10.3310/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 2013. 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

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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2013. 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

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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2013. 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

DOI: 10.3310/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 2009. 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 2008. 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 2014 15. Known as the Nichoson chaenge or Queen's Printer and Controer of HMSO 2013. 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

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 2010. The new Secretary of State for Heath pubished his first White Paper in Juy 2010. 1 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 2014 15. 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 2011. 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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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. 12 14 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. 23 25 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 2013. 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

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 2011. 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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Research methods This project used a mutimethods coaborative design invoving set-up interviews, focus groups, a management survey, documentation from participating sites, serious untoward incident narratives based on documentation and interviews, and management briefings (see detais in Appendix 8). The aim throughout was to engage participants as co-researchers, in formuating the origina proposa, in survey design and in seecting case incidents. The project stages are summarised in Tabe 1. Timescae and participating trusts The project was based in six acute hospitas, seected to provide geographica spread and variation in size and status. To maintain anonymity and confidentiaity, they were given pseudonyms. These hospitas are profied in Tabe 2. A trust is a pubic sector corporation and is not a trust in the ega sense. This mode was introduced in 1990 as part of the pan to deveop an interna market in heath services, with genera practice fund hoders buying care from independent providers. Trusts have a board with a chief executive and executive directors, and non-executive directors incuding a chairperson. Trusts are required to appoint an audit committee comprising non-executive directors (excuding chairpersons) to oversee finance and corporate governance. Foowing controversy and trade union resistance, the foundation trust concept was introduced in 2004. Foundation trusts have greater operationa and financia autonomy, under a icence granted by the foundation trust reguator, Monitor. The organisation structures and governance arrangements of foundation trusts encouraged them to operate ike businesses, with cose inks to oca communities through boards of governors comprising members drawn from the popuations that they served. A NHS trusts were expected to achieve foundation status by 2013 14. 33 In 2010 11 there were 258 hospitas in Engand, 34 but ony 172 acute trusts (of which around 140 had foundation status). The discrepancy is expained by the wave of mergers in the first decade of the 21st century, creating severa trusts that combined more than one hospita, such as Greenhi, Netherby and South Netey, which each operated two hospitas at different ocations. The seection of those trusts cannot be seen as a representative sampe in the traditiona, statistica sense. However, the aims of deveoping theory and practica guidance rey on the more powerfu concepts of anaytica refinement and naturaistic generaisation, rather than on statistica generaisation. 35 37 With regard to understanding the probems of impementing change foowing serious incidents, statistica generaisation is irreevant, but isomorphic earning is important. 38 Sampe size is not a concern in the TABLE 1 Project stages and timings Project stage Timing Description Stage 1: set-up January October 2009 Project aunch, recruit research feow, ethica approvas, advisory group, set-up interviews to gather background information on participating sites Stage 2: management focus groups January October 2010 Focus groups at each of six sites: identify motives, trends, contributions Stage 3: management survey August October 2011 Survey trust management popuations: reaities, changes, contributions Stage 4: management briefings June 2011 March 2012 Feed back findings in briefing groups; expore impications for practice Stage 5: managing extreme events January 2010 March 2012 Incident narratives, focusing on change foowing extreme or serious events Stage 6: pubication and dissemination Ongoing, fina report June 2012 Fina report, further dissemination Queen's Printer and Controer of HMSO 2013. 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. 5

AIMS, BACKGROUND AND METHODS TABLE 2 Participating acute hospita trusts Trust Sites 2011 12 ( ) a Staff a Beds a FT b CEs c Big issue d Burnside 1 120M 2400 400 No 2 PCT reations Cearview 1 590M 7000 1150 Yes 2 Site deveopment Greenhi 2 420M 8000 1100 Yes 1 Emergency targets Netherby 2 240M 4200 600 No 5 Ageing estate South Netey 2 490M 9000 1150 No 2 One site by 2014 Watte Park 1 240M 3400 700 No 2 Merger pans a b c d Figures for annua income, staff (headcount) and bed numbers are approximate, as these were under constant adjustment during this project. Indicates whether or not each hospita had foundation trust (FT) status at the time of this project. The four that did not were in the process of deveoping appications. Indicates the number of chief executives (CEs) (permanent and acting) that each hospita had during this project, from 2008 9 to 2011 12. Indicates the main management issue facing the board of each hospita (apart from finance, which was a major concern for a six hospitas, particuary from 2010). context of these research and practice-reated aims. Nevertheess, those six trusts can be regarded as broady representative of the acute sector as they operate in the same poicy, reguation and funding environment, facing the same government demands and pubic expectations, with simiar interna structures, working conditions and terms of empoyment. Empirica support for a caim to representativeness comes from the observation that the midde management experience dispayed broad simiarities across those six trusts, despite their differences in size, structure, ocation, status and probems. There were differences, of course, but the simiarities were more striking. Coaborative research design Coaborative research designs, athough not without probems, have been shown to be effective in transating research into practice in heath care. User engagement contributes to the deveopment and dissemination of findings, and to buiding research capacity among those invoved. 39 This project adopted a coaborative design, with five aspects. First, in negotiating access to participating trusts, the draft research proposa was circuated to chief executives and other board-eve directors for comment. The draft was atered as a resut of feedback received. Second, one of the questions asked in management set-up interviews concerned desirabe outputs from this project. Recurring themes incuded the vaue of fresh evidence to support eadership and management deveopment, managing a compex and contradictory agenda and impementing change to improve patient safety. Third, we ran a project aunch event foowed by three update workshops at which findings were fed back to participants for critica comment, focusing aso on the impications for practice. Fourth, project findings were fed back to individua trusts in management briefings, triggering discussions around interpretation and emphasis and practica impications. Finay, this project was assisted by a SDO management feow, on fu-time secondment from Cearview for 8 months and attached to the project part-time over 2 years. We aso estabished an advisory group with eight members (see Appendix 2). Two were senior academics with experience of heath-care management research. The other six incuded two in senior nationa NHS roes, an acute trust research and deveopment manager, two freeance consutants speciaising in heath-care management deveopment and our SDO management feow who came from an operationa management roe at Cearview. The managers in this group outnumbered the academics. Together they provided a vauabe sounding board and source of ideas and advice on project methods and focus, interpretation of findings and appications, and dissemination methods. 6 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Data coection Information came from five main sources: interviews, focus groups, survey, briefings and incident narratives. That information was compemented by documentation (annua pans, strategy documents, reports and accounts, board agendas and minutes, NHS staff survey resuts and trust newsetters), much of which was in the pubic domain and avaiabe from trust websites. Tabe 3 summarises the numbers of participants invoved in each stage of the project, at each of the six acute trusts. The project stages invoved the foowing activities. Stage 1: set-up 1. Coection of background information on research sites through set-up interviews and internet downoads. 2. Recruiting, orienting and equipping research feow. 3. Coating and reviewing iterature on midde management, the management of extreme change and management contributions to heath-care organisation outcomes. 4. Ethica approvas, governance checks and research passports. Set-up interviews had three objectives (see agenda in Appendix 2): first, to estabish the key groups of midde and front-ine managers with whom it woud be appropriate to run focus group discussions; second, to gather background on each trust and its management agenda; and third, to estabish ogistica arrangements for distributing project information. Stage 2: management focus groups The origina proposa was to run four focus groups at each participating site, invoving around 100 managers in tota. These discussions generated information concerning the changing nature of midde management work, and issues arising in those discussions aso contributed to the design of the survey (see participant information and topic guide in Appendix 2). As Tabe 3 shows, however, over 230 managers participated in 40 focus group discussions. The main reason for exceeding the origina target ay with repies to the interview question concerning the midde management groups to invove in this project and who woud not be covered with ony four focus groups. The widey distributed nature of the management popuation in an acute trust is expored in Chapter 2. At two trusts, South Netey and Watte Park, arranging focus groups proved to be a ogistica probem. Ony two groups were run at South Netey and, athough five were run at Watte Park, one reied on interviews with cinica directors with whom we were never going to be abe to meet as a group. TABLE 3 Project participant numbers Trust Set-up interviews Focus groups a Incident interviews b Survey Briefings c Burnside 10 47 (5) 15 108 16 Cearview 24 52 (12) 14 250 78 Greenhi 13 33 (7) 2 77 85 Netherby 17 38 (9) 6 86 40 South Netey 12 23 (2) 0 90 2 Watte Park 17 41 (5) 9 0 0 Tota 93 234 (40) 46 611 221 Tota project participants 1205 a b c Number of participants (number of focus groups). Incident narratives were aso supported by interna documentation; one trust did not identify a suitabe incident. Briefings participation was uneven, refecting difficuties in finding meeting times for hospita management groups from eary 2011. Queen's Printer and Controer of HMSO 2013. 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. 7

AIMS, BACKGROUND AND METHODS Stage 3: management survey The aim of the management survey was to buid on the quaitative information from interviews and focus groups, and to generate evidence from a arger sampe on the nature of emerging pressures and demands, and the impications for management practice. The aim was to survey the entire midde management popuations in the six participating trusts, but this was not possibe. The pan was to use a 60 40 design with around 60% of survey items common to a sites, for comparison and benchmarking purposes, and 40% taiored to oca priorities. However, as the survey was being designed eary in 2011, pressures on trust managers' time increased sharpy, and three trusts decided not to compement the survey with their own questions. Findings are expored in Chapter 5 and fu detais of the survey design, administration and anaysis are provided in Appendix 3. Stage 4: management briefings Starting in the second quarter of 2011, we offered management briefings to give participants an opportunity to assess the findings and their impications. These were aso opportunities for respondent vaidation, to check interpretations and to expore impications for practice. The imited amounts of time that managers were abe to give to these meetings meant that there was often itte chance for extended discussion. However, the broady favourabe responses to these presentations did provide reassurance with regard to the main findings. Stage 5: managing extreme events This stage of the project focused on the management processes invoved in impementing change foowing serious or extreme incidents. 40 The aims incuded deveoping an understanding of processes that have rarey been investigated from a change management perspective, and deveoping frameworks of practica vaue in such settings. Patient safety and serious incident investigation are areas in which considerabe amounts of work theoretica and practica aready exist. However, the focus of that commentary concerns investigation methods to understand incident causaity, and protocos to improve safe practice. The impementation of changes to practice is rarey automatic or straightforward, and there are gaps in our understanding of the potentia probems. The aim, therefore, was to document narratives of successfu and ess successfu attempts to impement change foowing serious incidents, to identify the conditions that shape the outcomes. The incidents discussed in this report are isted in Tabe 4. The outcome in one of these incidents, concerning the handing of the Costridium difficie outbreak at Burnside, was sustained success. Change foowing the other incidents, however, was probematic. Because of space constraints, four of these incidents are discussed in Chapter 6 and one is reported in Appendix 4. Stage 6: pubication and knowedge transfer Pubication and dissemination traditionay foow project competion. In this case, however, the intent was to deveop outputs from the project from an eary stage, particuary when these had impications for management practice. We wanted to generate high-impact, readiy accessibe modes of communication, TABLE 4 Change foowing serious incidents: incident narratives Serious incident Trust C. difficie outbreak Burnside Patient death, drugs interaction Menta heath patient suicide Surgica patient misidentification Norovirus outbreak (see Appendix 4) Cearview Cearview Cearview Watte Park 8 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 which nevertheess maintained the integrity and, where appropriate, the compexity of the issues at stake and impications for management practice. Outputs have incuded a series of research briefings, a podcast, a magazine artice, a contribution to the Heath Service Journa onine resources section and conference and seminar presentations (see Appendix 5). Data anaysis Tabe 5 summarises the approach to data anaysis, inking information sources to the project themes. Methodoogy assessment This study has a number of imitations. First, data coection was uneven across the six participating trusts, mainy because of the growing pressures on hospita management and the difficuties in arranging meetings. Second, the extended time frame potentiay jeopardises the reevance of information gathered towards the beginning of the project (athough many of the pressures raised at that stage have intensified since). Third, coverage of this range of themes across six trusts has perhaps been achieved at the expense of depth; it was not possibe to foow up many interesting issues because of time pressures on both researchers and participants. Fourth, this quaitative study of management contributions deveops concusions that woud benefit from quantified support. Probems arose more with regard to the context in which this project was conducted than with the project design. The context invoved changes that were unprecedented in scae and pace, and which made exceptiona demands on NHS staff time, particuary those with management responsibiities. We attempted to arrange 1-hour interviews with individuas and 1-hour focus group meetings with around haf a dozen managers at a time, when operationa pressures were aready requiring them to work we beyond contract hours. It was aso difficut to arrange for the distribution of, and encourage responses to, the survey because of pressure on resources. Athough we were abe to generate outputs from an eary stage, the sower than expected accumuation of data deayed the data anaysis process. Major outputs have thus aso been TABLE 5 Data anaysis and project themes Stage, ink to themes Anaysis, what this reveaed 1. Set-up interviews Context profiing, of participating trusts Managing reaities Outcomes: identify oca priorities and management agenda, factors shaping management reaities 2. Focus groups Content anaysis, identifying recurring themes Managing reaities Managing change Outcomes: identify pressures, trends affecting midde management, suggestions for strengthening management contribution 3. 60 40 survey Statistica anaysis: descriptive statistics and frequency distributions; content anaysis of open responses (one trust ony) Managing reaities Managing change Managing contribution Outcomes: sampe characteristics, motives and vaues, incidence and experience of new chaenges and trends, factors and practices impacting effectiveness, components of enabing and disabing environments for management work, changing patterns of management activity 4. Briefing groups Content anaysis, identifying recurring themes Managing contribution Outcomes: respondent vaidation, practitioner check on anaysis, interpretations, and impications for practice 5. Extreme events Visua mapping and event sequence anaysis, of incident narratives Managing change Managing contribution Outcomes: identify recurring success and probem patterns in extreme change processes, contingency framework based on comparisons of incidents and contexts Queen's Printer and Controer of HMSO 2013. 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. 9

AIMS, BACKGROUND AND METHODS deayed, and deveoping the pubications stream further is a priority foowing the competion of this project report. Nevertheess, the project design and methods aowed us to construct rich pictures of the changing reaities of midde management work in acute settings and management contributions to organisationa and cinica outcomes and how those contributions coud be strengthened. The incident narratives have generated fresh insights, theoretica and practica, for streamining change processes and contributing to patient safety. Participants saw this project as vauabe and timey, and none refused to be interviewed. Focus groups invariaby ran beyond their schedued hour as participants wanted to continue discussion. We were invited to incorporate management briefings in trust eadership deveopment programmes. We were asked to run additiona management skis sessions, particuary with regard to the deveopment of infuencing and poitica skis, and on impementing change after serious incidents. Informa feedback from managers on project outputs has been highy favourabe. We have aso deveoped interesting and vauabe suggestions for further research. 10 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Chapter 2 The NHS management popuation Names, ranks and numbers We want to turn this into a great organisation, a great pace to work. We need to engage peope or ose taent, especiay in genera management roes. Retaining taent in management roes is going to be a probem. They coud just wak away to other sectors. Director, Greenhi There is a widespread perception that the NHS is bureaucratic and overmanaged by pen-pushers and grey suits. 31,41,42 Management costs were thus a popuar target for poiticians during the ife of this project, particuary approaching the genera eection in May 2010. 43,44 In exporing the NHS management popuation, this chapter reaches four concusions: 1. Evidence suggests that the NHS is undermanaged, despite caims about disproportionate increases in management numbers, and the composition of the NHS workforce is stabe. 2. The proportion of staff with manageria responsibiities is much higher than suggested in officia statistics, which do not recognise many midde managers or those whose roes combine cinica and manageria responsibiities. 3. Acute trust management incudes pure pays with manageria roes and hybrids with combined cinica manageria duties; hybrids outnumber pure pays by four to one. 4. The obsession with management numbers and costs overooks more significant issues concerning management capacity and the contributions that midde and front-ine management make to cinica and organisation outcomes. Management numbers The NHS Information Centre coates annua workforce census figures (www.ic.nhs.uk). The overview in March 2011 reported that, on 30 September 2010, as fiedwork for this study began, the NHS in Engand had neary 1.2 miion empoyees (fu-time equivaent or FTE, Tabe 6), incuding 40,094 managers and senior managers (Tabe 7). Between 2000 and 2010, management numbers increased by 65%. The same cacuation for 1999 2009 reveaed a rise in management numbers of 84%. Tota NHS empoyment rose by 30% over this period. TABLE 6 Tota NHS empoyment 2000 2010 % increase Headcount 1,118,958 1,431,557 28.0 FTE 892,620 1,186,571 32.9 TABLE 7 NHS managers and senior managers 2000 2010 % increase Headcount 25,256 41,962 66.1 FTE 24,253 40,094 65.3 Queen's Printer and Controer of HMSO 2013. 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. 11

THE NHS MANAGEMENT POPULATION Athough the press made an issue of this 80 30 disparity, basic arithmetic suggests a more prosaic concusion. The disparity arises from the difference in the bases of the cacuation, which is over a miion in one case and around 20,000 in the other. Percentage cacuations produce higher figures with smaer bases. For exampe, when team membership grows by ony one person from two to three, that is a 50% increase. When team numbers swe to 101 from 100, that is a 1% increase. The Information Centre figures (Tabe 8) show that managers represented just under 3% of the NHS workforce (FTEs) in 2000 and just over 3% in 2010 hardy a dramatic increase. The census pubished in 2012 shows that tota empoyment fe to 1,193,334 (headcount) by November 2011 and the number of managers and senior managers aso fe to 3.2% of the tota. It is, however, appropriate to expain the increase in management numbers since 1999. Part of the expanation ies with the 30% increase in the numbers of staff requiring recruitment, seection, coaching, mentoring, supervision, appraisa, discipine, deveopment management. The increase was aso ikey to have arisen as a resut of other demands: 45 pursuit of foundation trust status, deveoping service-ine management waiting times and other targets, outcomes, performance standards Quaity, Innovation, Productivity and Prevention (QIPP) agenda word-cass commissioning, creation of cinica commissioning groups patient choice, eectronic booking, independent treatment centres payment by resuts, changes to tariffs, fines making 20B efficiency savings by 2015 constanty changing reguatory, auditing and accreditation regimes serious incident and never event investigation and reporting systems Monitor and Care Quaity Commission (CQC) compiance processes and quaity accounting. Drawing from Biney's Database of NHS Management, Washe and Smith 31 arrive at simiar concusions. Athough using information gathered for commercia purposes, with different incusion criteria, Biney's data have been coected in a consistent manner for a considerabe period, and revea trends simiar to those in the Information Centre figures. According to Biney's Database, NHS management numbers in the UK rose by 28% between 1997 and 2010 (Tabe 9). Washe and Smith note that NHS spending over this period increased by 105% in rea terms, from 60B in 1996 7 to around 123B in 2010 11 (at 2011 prices). They concude that the management workforce has not expanded disproportionatey, having not ony more staff, TABLE 8 Managers and senior managers as percentage of tota NHS empoyment 2000 2010 Headcount 2.3 2.9 FTE 2.7 3.4 TABLE 9 NHS managers 1997 2010 Biney's Database Year Engand UK 1997 20,029 24,822 2000 18,462 22,366 2010 27,413 31,871 12 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 but aso more money, to manage. Biney's Database aso shows that management numbers in acute services (across the UK) have been reativey stabe, with 14,810 in 1997, 12,642 in 2000 and 13,985 in 2010. How does the NHS compare with other sectors? The Office for Nationa Statistics Labour Force Survey shows that around 15% of the tota UK workforce are designated managers and senior officias. This proportion has changed itte in the past decade, rising from 13.6% of a those in empoyment in 2001 to 15.6% in 2010 (www.statistics.gov.uk/statbase/product.asp?vnk=14248). With ony 3% of the workforce in management roes, the NHS may be short of management expertise. Management costs The question of management numbers is inked to costs, which, in a cimate of goba recession and domestic austerity, were the subject of debate. This debate was not new. In 2001, Appeby 46 reported on government's war on management costs (synonymous with managers/bureaucrats), asking, what eve of management costs shoud the NHS expect to bear in order to have a we-managed service? The New Labour administration wanted to cut NHS management costs by 1B over 5 years from 1997. Appeby 46 aso noted that Managers are not seen by most of the pubic as adding any vaue to the NHS or patient wefare. Indeed, most woud ike to see fewer managers and, yes, more doctors, more nurses, more beds. Reducing bureaucracy is perenniay popuar. McLean 47 noted that management costs were around 3% of the annua service budget in 2010. In comparison, US charities spend between 4% and 8% of revenue on management. The estimate for UK charities is between 5% and 13%. 48 McLean 47 cites these figures as evidence that the NHS is undermanaged, a situation that woud be exacerbated, he argued, by the poicy of cutting management costs by 45% by 2014 15, pointing to the scae of the financia chaenge facing the service and the potentia ack of management capacity to dea with it (p. 3). Drawing on an anaysis by McKinsey, Santry 43 reports that management accounted for 1.5% of the tota NHS budget in 2009, putting the UK at number 18 in a ist of 23 goba heath systems. Management in other countries consumed much higher proportions of their heath-care budgets, incuding in Mexico (11.8%), the USA (7%) and France (6.8%). Santry was responding to a caim by the Secretary of State for Heath that there was no comparative internationa evidence to show that the NHS had ow management costs. An undermanaged service? The NHS Confederation 49 argued that, as one of the argest empoyers on the panet, spending over 2B a week and meeting the heath-care needs of around 60 miion peope, the proportion of managers in the NHS is ow. The evidence indeed suggests that the NHS has ean management. The wisdom of poicy to cut management numbers and costs is thus in doubt, as this weakens the motivation and commitment of managers, and diutes the management capacity to impement change. The King's Fund 42 commission on management in the NHS concuded that, It might just as sensiby be asked, how can it be run effectivey with ony 45,000 managers? (p. 4). Pure pays and hybrids Other evidence shows that the officia figures underestimate the numbers of those with either a pure management roe or a hybrid roe combining cinica duties with manageria responsibiities: pure pays: roes that are whoy manageria hybrids: roes that combine cinica and manageria responsibiities. The NHS Information Centre data do not count as managers any cinica and scientific staff hoding hybrid manageria roes; however, if hybrids as we as pure pays are counted, then the proportion of NHS staff in management positions is not 3% but around 30%. Queen's Printer and Controer of HMSO 2013. 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. 13

THE NHS MANAGEMENT POPULATION Beyond the G matrix Empoyment figures compied by the NHS Information Centre 50 were based on the Occupationa Code Manua Version 9. Managers were covered in the G matrix for administration and estates staff. This incuded those with overa responsibiity for budgets, staff or assets, or who are hed accountabe for a significant area of work. This incuded chief executives, board directors and deputies, and service managers reporting to them. However, managers who had to be quaified as doctors, nurses, therapists, scientists or ambuance personne were coded in their professiona area, such as cinica directors, modern matrons and ward sisters, and aboratory supervisors. Trust chairpersons and non-executive directors did not appear in the management numbers either. They were coded in the Z matrix for genera payments aong with Macmian and Marie Curie nurses. Other ine managers, team eaders and supervisors were coded as cerica and administrative. They were excuded from management numbers because they do not have responsibiity for a significant area of work/budget, incuding ine managers for whom management is ony a portion of their roe who may aso act as anaysts or in some other administrative or cerica capacity. This understates the significance of such roes ward managers, outpatient department management, the management of diagnostic units and ceaning, catering and portering supervisors. Those staff can have a major impact on hospita performance and reputation. Staff coded in the cerica and administrative category in the G matrix, incuding those with manageria responsibiities, appeared in the census as support to cinica staff. In 2010, support staff accounted for 26.5% of a NHS empoyees in Engand, a proportion that had aso been stabe for a decade. The proportion of staff in centra functions finance, personne, information was aso reativey stabe, at 8% of empoyees in 2010. Who are these uncoded midde managers? One of the questions in the project set-up interviews was: Who woud you incude in the midde management popuation of the trust the key categories and/or groups to whom we shoud be speaking? Responses incuded hybrid roes (medica director, cinica director, senior/ead nurse, midwifery manager, modern matron, ward sister, speciaty ead, aboratory team eader) as we as pure pays (deputy/assistant director, genera manager and department head). Using an organisation's own definition of midde management is a strategy advocated by Currie and Procter, 51 and adopted in this project. The workforce information departments (who coate the census figures for the NHS Information Centre) in Cearview and Greenhi were asked to estimate the tota management popuations of their trusts, counting pure pays and hybrids. This was based on a briefing on the traditiona definition of management in terms of panning, organising, supervising, directing, co-ordinating, reporting and budgeting, or POSDCoRB, 52 and aso taking responsibiity for human resource management, and the impementation of service improvement, into account. If a roe incudes some or a of those activities then it is categoricay a management roe. The estimates are shown in Tabe 10. In both trusts, around one-third of staff had manageria roes, with pure pays accounting for 6% of the tota. It is aso important to note that hybrids in both cases outnumbered pure pays by four or five to one. The head of eadership and organisation deveopment at Greenhi fet that these estimates were ow. Asked to make an informed guess about the actua figure, she repied, I think we're ooking at 35 to 40 per cent. An overmanaged service? The NHS may be viewed as undermanaged, with ony 3% of its 1.4 miion empoyees in management roes. Knowing that at east one-third of staff (in acute trusts) have manageria roes, can we concude that the service is overmanaged? This raises the question of management capacity. Management capacity can be defined as the abiity of the function as a whoe to respond effectivey to the demands paced on it at any given time. The management agendas of the trusts coaborating in this study were engthy, compex and fuid (see Chapter 4). Different profies of pure pays and hybrids may be 14 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 10 The management popuations at Cearview and Greenhi Cearview Greenhi Tota staff (FTE; 2011 a ) 7137 6254 No. with management responsibiities No. with management responsibiities as percentage of tota staff 2380 1940 33.3 31.0 No. of pure pays 398 405 Pure pays as percentage of tota staff Pure pays as percentage of a management 5.6 6.5 16.7 20.9 a Cearview at Apri 2011 and Greenhi at September 2011. equay effective in the context of different oca conditions, past histories and current agendas. It is not possibe to assess capacity simpy by comparing numbers. Fewer pure pays may mean ower management costs, but that coud increase the burden on hybrids, reducing time for patients, professiona deveopment and innovative service improvements. That may in turn ead to the appointment of more cinica staff to compensate, canceing the cost advantage of having fewer professiona managers. With regard to the 3% versus 30% question, at east four other factors impinge on the management capacity of an acute trust. First, the other 30% are not a FTEs; most are hybrids. One senior hybrid asked about the mix of cinica and manageria responsibiities in nursing roes repied: Head nurses are 50 50. They're responsibe for the manageria nursing aspects in their directorate. But I hod them accountabe for nursing professiona issues as we. For a matron, I woud expect that to be very much more cinica. And probaby it shoud be 75 25, cinica manageria. For a ward sister, the idea is that they shoud have two days a week where they can dea with the manageria eements of their roe, but it's aso about making sure standards are adhered to. So probaby a 60 40 spit. In your judgement, are some of those staff spending more time on their management responsibiities than they shoud? No. I woud say it's the other way around. They don't get enough management time. Director, Netherby Interviews with modern matrons esewhere suggest that this baance of responsibiities varies from trust to trust, and fuctuates over time, depending on the management agenda. Second, despite our previous definition, some pure pays have speciaist non-manageria responsibiities and so they are not necessariy each a fu FTE. For exampe, one manager commented as foows about her manageria speciaist responsibiities: Question: Is my profession manager or trainer/coach? Answer: Trainer/coach. Therefore, when answering what percentage do I manage/ead versus what is practica/speciaist, I'd say 70 30. I do have a practica/speciaist roe I fufi that is not management. There is cear water between the two, Queen's Printer and Controer of HMSO 2013. 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. 15

THE NHS MANAGEMENT POPULATION and I suspect that many others wi say the same. Few of them wi see themseves as NHS managers whoy, rather a speciaist first, in a management roe, but their oyaties are often to the profession they trained hard in. Senior manager, Greenhi Thus, 100 pure pays does not necessariy equate to 100 FTE managers. Athough no onger empoyed fu-time in a cinica capacity, many pure pays have a cinica background (such as nursing) that they bring to their reationships with cinica staff, and use to inform decisions and judgements. Some maintain their registration, and ask their workforce information offices to code them with their profession in the annua census figures, and not in the G matrix as managers. Third, most hybrids have had imited management education, beyond short courses. Pointing to the piecemea on the job management deveopment of medica staff, Giam 53 argues that the idea that a doctors can just manage is hopeessy naive (p. 1). Short courses incude The King's Fund management and eadership for cinicians course, which runs over 5 days, and Leading an Empowered Organisation (LEO), which was a 3-day course (now discontinued) for staff (incuding nurses) in management and supervisory roes. A master s degree in business administration takes a year of fu-time study to compete; few cinica staff have the desire, time or financia resources to obtain this quaification. During this project, Cearview, Greenhi and South Netey impemented their own eadership and management deveopment programmes. But these sti amounted to more short courses, abeit intensive and taiored. The management capabiities of many hybrids are thus dependent on imited educationa input and considerabe on-the-job earning: We don't have any manageria training and ots of work is eft to us. I expect that in the future we wi be eft to make more decisions. There is more workoad. You have to do appraisas, you are asked to create a new poicy and deiver presentations and you are expected to do more. Mixed focus group, Greenhi I've been in post for three years, and I want promotion. Are they deveoping me into a matron's roe? There is no ongoing deveopment. Ward managers are just eft to get on with it. You are eft on your own. Find your own deveopment. The one-to-one meetings that we have with more senior management are a about operations and finance. Ward sister, Netherby Fourth, many hybrids do not view themseves as managers or they use the abe reuctanty. In 2010, ward managers at Netherby voted to change their job tite to ward sister. Other exampes incuded: I've been a consutant nephroogist since 2003, and I've been invoved with the emergency department project since 2005. The roe of cinica ead is manageria if you want to ca it that. In the emergency department project, this has invoved structure change. But management has connotations among cinicians reating to stick not carrot. Managers are peope who withhod resources rather than try to improve services. My roe is more of a eadership and organisation deveopment roe, much wider than management. Cinica director, Greenhi I woud describe my roe as cinica eadership. I'm not nursing, not hands on. I am not at a manageria. My roe is professiona eadership. But this does infuence behaviour, practice, change, service improvement, so manageria in those senses. The senior staff on the wards have manageria responsibiity; ward sister, charge nurse are front-ine managers. Matrons and head nurses are midde management. I have a manager roe, but I have professiona accountabiity, so the emphasis of my roe is with professiona eadership. Senior nurse manager, Netherby 16 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 These participants were more comfortabe describing themseves as eaders. Before fiedwork commenced, we were instructed by a senior manager at South Netey to change the subtite on the project documentation, from midde and front-ine managers, so that this woud appear as a study of manageria and cinica eads. These views refect a trend in the pubic sector to vaue and promote eadership at the expense of mere management. 54,55 Mintzberg 4 offers a straightforward resoution to the eadership versus management debate. Asking if one woud ike to be managed by someone who doesn't ead, or ed by someone who doesn't manage, he concudes that, We shoud be seeing managers as eaders, and eadership as management practiced we (p. 9, itaics in origina). With a simiar view, and using managers and eaders interchangeaby, Quinn et a. 56 argue that, we want to distinguish between individuas who happen to have management positions and individuas who truy dispay eadership in their management of others (p. 333). The evidence from this project demonstrates that, if the distinguishing features of eadership concern designing, inspiring and driving change, then midde management roes in the NHS are indeed a bend of management and eadership. To iustrate how pure pays and hybrids popuate a hospita management structure, Figure 1 shows the organisation chart for the medicine division at Cearview. This division had 350 beds in 16 wards, empoying 1200 staff (headcount). The division's budget in 2010 11 was over 80M, with target savings of around 5M. The organisation chart identifies 21 pure pays and 80 hybrids. In other words, as indicated previousy with regard to what appears to be the typica baance of roes at trust eve, the ratio of hybrids to pure pays in this division was around 4 to 1. Finding the front, defining the midde For the purposes of this project it proved difficut to define unambiguousy the front ine in reation to the midde. Definitions provided by various commentators suggest that this shoud not be a probem. However, three considerations appy. First, in acute care, the management front ine is mobie. Second, the hybrids who occupy this fuidic space have onerous manageria responsibiities that infuence quaity of patient care, as we as organisationa performance. Third, the distinctions between roes in this ambiguous zone are more important than whether they are defined as midde or front ine. We have thus dropped the phrase front ine from discussion. The term midde management reates to anyone with manageria responsibiities who does not sit on a hospita board of directors. Distinctions between roes wi be drawn with reference to specific job tites. There are particuar reasons for viewing ward sisters as midde, not front-ine, managers. First, their roes are simiar to those of matrons and senior nurses, to whom they report. Second, they are mini-genera managers, controing a budget, overseeing the deveopment and morae of nursing staff, supporting medica staff, deivering service improvements and supporting and improving the patient experience. 57 Third, the manager subordinate reationship they have with other nurses is burred, as staff nurses routiney step up to cover for ward sisters in their absence. Fourth, with their operationa experience, they act as intermediaries between senior management and day-to-day patient care. 58 60 Finay, it has been suggested that management reguation shoud not stop at board members, but shoud incude ward managers. 61 The ward sister's experience is a midde management experience. Concusions and impications Composition and capacity The officia census shows that around 3% of NHS empoyees are managers and senior managers. In contrast, when midde managers and those hoding hybrid cinica-manageria roes are incuded, the actua proportion of staff in an acute trust with manageria responsibiities is around 30%. Management is a widey distributed function, not confined to a sma cadre or eite. Queen's Printer and Controer of HMSO 2013. 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. 17

THE NHS MANAGEMENT POPULATION Divisiona director medicine Associate director of operations a Operations a manager Operations manager Operations manager Divisiona ead nurse Deputy operations a manager Senior cinica nurses/ahp ead (5) Deputy operations a manager Senior cinica nurses (4) Deputy operations manager Senior cinica nurses (3) Key to Hybrids Divisiona support managers (2) Divisiona support managers (3) Divisiona support a manager management Pure pays Cinic managers (4) Cinic co-ordinators (4) 17 senior sisters/ ward managers (B7) 20 senior sisters/ ward managers (B7) 29 senior sisters/ ward managers (B7) Nursing staff and heath-care assistants report to senior sisters Admin staff in six cinics and appointments centre report to cinic managers Medica secretaries, other admin staff and endoscopy report to divisiona support managers Services: Division of medicine for the edery, gastro, endoscopy, panned short stay unit, ysosoma storage disorders, infectious diseases, cinica pharmacoogy Rheumatoogy, cardioogy, aergy, dermatoogy, genitourinary medicine, MetBone, appointments centre, outpatient cinics Stroke, respiratory, rena, hepatoogy, nephroogy, ung function, smoking cessation, diabetes FIGURE 1 Cearview Hospita medicine division organisation chart (October 2011). a, Managers with cinica backgrounds. AHP, aied heath professiona. There is itte or no evidence to suggest that the NHS is overmanaged. The proportion of staff in management roes is (officiay) much ower than the a-sector UK average. The (officia) cost of management is simiar to or ower than management costs in comparabe settings, and is ow on internationa comparisons. Support for the argument that the service is overmanaged reies on a fawed understanding of the arithmetic of percentage cacuations. However, numbers and costs are ess significant in reation to patient care, service improvement and overa performance than the management capacity of acute trusts. NHS management has been equated with unnecessary bureaucracy. As ater chapters revea, this caricature is inaccurate. Cuts in the numbers of pure pays in acute settings coud have serious consequences for the workoads of hybrids who woud have to cover the resutant gaps, uness the scope of trust management agendas were to be reduced and simpified, and there is itte sign of that happening. A poicy 18 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 of cutting management costs coud thus jeopardise the effective impementation of other structura, reguatory and financia reforms, and coud aso jeopardise patient safety through increasing the management pressures and demands on those with hybrid responsibiities. The denigration of NHS management, whie resonating with pubic sentiment, damages the reputation, engagement, goodwi and motivation of a group that is key to impementing government poicy, meeting nationa targets and maintaining the efficiency, quaity and safety of day-to-day patient care. Athough derogatory comments are presumaby aimed at pure pays, the resutant image of management is a deterrent to cinica staff who may be invited to take on management roes. Potentia candidates see through the ambiguous terminoogy of eadership, and have a cear understanding of the nature and perception of the management positions that they are being asked to assume. Nationa rhetoric thus reinforces the perception of medica staff that coeagues who have taken management roes have gone over to the dark side. As it is government poicy to encourage cinica staff to accept greater management responsibiities, this consequence is perverse. Impications for practice One impication for practice concerns the issue of management capacity, which in an acute trust, and based on the evidence from this project, can be seen as a product of: 1. management numbers 2. individua capabiities 3. engagement and motivation 4. organisationa resources and infrastructure the enabing environment 5. the quaity of cinica-manageria coaboration 6. the abiity to generate requisite variety. Ashby's aw of requisite variety 62 argues that the management function must be abe to generate at east the same eves of variety and compexity as the system being managed can adopt. Variety and compexity are required to dea effectivey with variety and compexity; responses to compexity are often mistakeny aimed at simpification. The ack of mutipe perspectives and diversity in thinking has been shown to reduce organisationa resiience and contribute to system faiures. 63 A management function whose members come from a range of different backgrounds shoud be abe to generate greater diversity than a more homogeneous group; the quaity of their coaboration is therefore a key factor. Echoing the notion of distributed eadership, forms of management in the pura, with mutipe coaborators, can thus contribute significanty to capacity. 64 This issue wi be expored further in Chapter 7. This assessment assumes that it is possibe to measure those factors, to operationaise the formua. This is probematic in practice, as each set of factors has mutipe dimensions, and the understandings and definitions of those terms wi differ from one setting to another. Nevertheess, in principe, this mode summarised in Figure 2, distinguishing individua and organisationa dimensions offers a starting point for exporing management capacity at system and trust eves. Most of the evidence from this study suggests either that acute trusts acked management capacity or that avaiabe capacity was underutiised. Symptoms of undercapacity that were observed incuded probems arranging meetings due to busy diaries, meetings canceed at short notice, reguar evening and weekend working, managers saying that they coud not cope with the workoad, comments about our firefighting cuture and hiring externa management consutants to hep manage crises. Symptoms suggesting that capacity was not being used effectivey incuded the circuation of irreevant and dupicated e-mais, staff performance issues not addressed, mutipe unpanned interruptions throughout the day, minuted actions from meetings outstanding for months, frustration at bureaucracy impeding simpe service improvements, managers criticised for decisions within their remit, experienced cinica and manageria staff carrying out basic administration, penaties for minor faiures to achieve goas or targets and Queen's Printer and Controer of HMSO 2013. 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. 19

THE NHS MANAGEMENT POPULATION The management capacity six Individua dimensions Capabiities Engagement and motivation Numbers Organisationa dimensions Resources and infrastructure Cinica manageria reationships Abiity to generate requisite variety FIGURE 2 Dimensions of management capacity. managers compaining, just et me run my business. Ideay, responses to an assessment suggesting that a trust or division is underutiising management capacity incude: redesign of cumbersome and dated systems and procedures cear corporate e-mai poicy to avoid dupication and overoad more prepanning, no crisis of the day, ess firefighting streamined, simpified decision-making processes increased autonomy for managers impementing service improvements redesigned information technoogy (IT) systems to provide timey and usefu information shift senior management stye away from ony bame, avoid praise shift senior management stye to high trust high autonomy. Impications for research Assessment of management capacity shoud be a fruitfu area for further research, exporing the nature, source, assessment and impications of varying capacity eves. Improved understanding of capacity woud provide a usefu counterbaance to crude arguments about the vaue and contributions of management based on numbers and costs. As capacity is an organisationa construct (incorporating individua dimensions), this suggests a shift in the research agenda with theoretica impications for heath-care management, and with regard to management theory in genera. This shift in emphasis is summarised in Tabe 11. These recommendations are not particuary nove. Management and organisation studies research has been working in these directions for some time. However, a more thorough exporation of management function, process and capacity in heath care woud have potentia practica benefits for the service and the sector, as we as impications for the deveopment of genera management theory. TABLE 11 Shifting the emphasis in management research Conventiona approach What individua managers do Management roes Management numbers and costs Compementary perspective What the management function contributes Management processes Management capacity 20 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Chapter 3 The institutiona context The nature and significance of context The NHS, ike any other organisation, is embedded in a historica, sociocutura, economic and poitica context which shapes the norms, vaues and expectations that in turn infuence the structures and processes of the heath-care system. 65 The nature of, and reationships between, the dimensions of the institutiona context are critica to understanding the demands that are paced on the management function, and the changing nature of manageria roes. Context is not simpy a stage on which action takes pace. The context of an organisation is fuid and dynamic, infuencing and in turn shaped by organisationa events. 66 These inter-reationships do not necessariy generate a state of constant fux and indeterminacy. The institutiona context is aso responsibe for reinforcing and perpetuating organisationa characteristics, for maintaining patterns of continuity. For exampe, the so-caed postmodern trend for fat, fuid, agie organic structures that was supposed to sweep away traditiona, rigid, sow-moving bureaucratic structures has barey touched the NHS in its 60-year history. 67 Six dimensions of the context in which the NHS operates are identified (Figure 3). These concern the history of the service, the contemporary business of heath care, governance, reguation, finance and the roe of the media. These dimensions overap; discussion of reguatory regimes coud equay beong with governance, and discussion of heath care as a business with finance. The overarching aim of this discussion, however, is to expore reationships between the institutiona context and midde management roes. The main concusions from this anaysis are: History dimension. Athough subject to constant reorganisations, core features of the hierarchica, centray controed professiona bureaucracy appear to be reativey stabe. Rues, reguations and sow The business dimension The history dimension The finance dimension Dimensions of the institutiona context The governance dimension The reguatory dimension The media dimension Midde management roes FIGURE 3 Dimensions of the institutiona context of the NHS. Queen's Printer and Controer of HMSO 2013. 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. 21

THE INSTITUTIONAL CONTEXT decision processes can be beneficia, offering predictabiity and consistency, but can aso impede innovation and rapid change. The current reguatory regime is a egacy from a series of high-profie faiures, the most recent concerning events at the Mid Staffordshire NHS Foundation Trust ( Mid Staffs ). The goba financia crisis that began in 2008 ed to ongoing nationa austerity budgeting and to pressure on heath care to make major efficiency savings, of approximatey one-fifth of the annua spend of the service. Business dimension. The private and pubic heath-care sectors are now cosey intertwined. In hospitas, cinica services are structured and run as businesses within the business. Cinica and manageria staff are encouraged to adopt a more commercia orientation and to deveop new business modes, manageria and process innovations, inventive uses of new technoogies, pubic private coaborations and competitive strategies. A key chaenge concerns baancing efficiency and productivity with quaity and safety of patient care. The NHS is aso expected to generate revenue from innovations and exports. Governance dimension. The government eected in 2010 embarked on a compex, rapid and controversia reorganisation of NHS structures. Some existing bodies were aboished (strategic heath authorities and PCTs) and new ones were created, incuding a Nationa Commissioning Board and oca cinica commissioning groups. Poicy to cut management costs generated considerabe resentment. The promised iberation, autonomy and empowerment were difficut to spot, and micromanagement continued. Reguatory dimension. Providers answer to many reguators, auditors, inspectorates and accreditation agencies (RAIAs), whose information demands overap and can be burdensome. Reguation has improved aspects of performance, but has not prevented systemic faiures in care. The reguatory regime extends to innovation, where the ca for a more creative, commercia approach is accompanied by a compiance framework, standardised efficiency measures, fines and an impementation board. In the wake of the Mid Staffs inquiry, some form of reguation of heath-care management was expected to emerge during 2012 13. Finance dimension. The Nichoson chaenge to find 20M efficiency savings between 2010 11 and 2014 15 was described as a NHS recession, a funding ice age and a perfect storm. Trusts from 2010 had to impement CIPs generating recurrent savings of 3 4% per annum, raising anxiety about job security among a staff incuding management. Athough cutting costs and improving productivity were over-riding issues, these actions had to be baanced with the priorities of improving the quaity and safety of patient care. Midde managers in particuar fet the need for financia management skis. Media dimension. The press rues of production mean that sensationa, dramatic bad news stories are more ikey to be reported than good news. The constant bad press infuences pubic perceptions of the service and its staff, and aso affects government poicy. Commentary supportive of management is rare; poor management is typicay bamed for system fauts and faiures, and a negative stereotype of managers as costy pen-pushing bureaucrats prevais, potentiay inhibiting motivation and recruitment. The six dimensions The history dimension The history of the NHS is a history of change. An organisation of this size and cost is unikey ever to be free from poitica intervention. As governments in the UK change at east every 5 years, the potentia for turbuence is high. During this project, the service witnessed shifting government priorities, new organisationa arrangements and reguatory systems and more high-profie events incuding faiures in care for the edery, 68 Winterbourne View 69 and faiures in care at Mid Staffs. 70 Subject to constant change, has the NHS now deveoped the agie, fexibe, non-hierarchica, organic, responsive attributes of the post-bureaucratic archetype? Commentators have been predicting the dinosaur scenario, the extinction of bureaucracy, for a century. Buchanan and Fitzgerad 67 argue that the NHS has become an accessorised bureaucracy. This has meant acquiring some fashionabe new practices and private sector terminoogy whie maintaining centra contro, compex structures, mutipe reguatory bodies and the proiferation of performance metrics. This echoes a previous study which concuded that, athough the fur 22 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 coat of structures had changed, the knickers of the power reations that underpin the professiona bureaucracy were intact. 71 The accessories, however, have improved access to and the quaity of patient care and contributed to reductions in waiting times and infection rates. 72 Bureaucracy brings the benefits of unity, co-ordination, precision, predictabiity, consistency, impartiaity, organisationa memory and continuity across governments. 73,74 The accessorised bureaucracy provides a stabe, predictabe system that aso features innovation and change, and may thus be a good hybrid soution. In terms of recent history (2009 11), four sets of events were significant. First, Next Stage Review was pubished in June 2008, 75 with a review 1 year ater. 76 This review noted the chaenges posed by demographic trends, rising pubic expectations and the rapid deveopment of new technoogies, and stressed the importance of improving the quaity and safety of care, putting fresh emphasis on the roe of cinica eadership. Second, the financia crisis forced the UK government to support domestic banks, at considerabe cost, eading to austerity measures to reduce the resutant deficit. The NHS was asked to find 20B of savings by 2014 15 through a quaity, innovation, productivity and prevention programme. 77 Deveoping cost improvements to reduce spending on the required scae consumed considerabe time and energy. Finding savings within one financia year was difficut; making recurring annua savings of 3 4% was a major chaenge. Third, the mortaity rate at Mid Staffs since 2005 ed to an investigation 78 and then to an independent inquiry, 70 foowed by a pubic inquiry. Probems were attributed to faiures in eadership and management, as we as to apses in cinica care. This incident ed to demands to reguate heath-care managers. 61 Fourth, the genera eection in May 2010 returned a coaition government that proposed a radica reorganisation of the structure, funding and reguation of the service. New egisation was to scrap existing bodies strategic heath authorities, PCTs and create others a Nationa Commissioning Board, cinica commissioning groups and Heathwatch Engand (a consumers' champion ). The White Paper 1 aso indicated a 45% reduction in management costs. One participant in this study described the Department of Heath as a hyperactive chid, overoading staff with untested ideas disseminated in vast amounts of unco-ordinated documentation that nobody had time to read (cinica director, Netherby). Many commentators questioned the wisdom of introducing such a major reorganisation, accompanied by massive budget cuts, whie reducing the numbers and costs of managers within 4 years. 79 The business dimension We need to earn better how to compete. We've got to run as a business now, we're beginning to get there, and pathoogy is at the forefront. We have a we equipped ab, we have senior management support, we deiver on targets, our finance is OK, haf of our business is with the trust and other hospitas, and the other haf of our business is with genera practitioners. In 2009, microbioogy and immunoogy started to offer fourteen new services. This is a growth business. Cinica director, Netherby Our future surviva wi depend on our abiity to adopt a more business orientated way of thinking and working whist being appraised for the quaity of our patient services deivered through effective manageria practice. Management deveopment programme brochure, South Netey When I speak to nurses and cinicians about the business, they physicay recoi. It does not come naturay to doctors and nurses to see that they are part of a business when they have signed up for a vocation. Operations manager, Cearview Queen's Printer and Controer of HMSO 2013. 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. 23

THE INSTITUTIONAL CONTEXT Foundation trusts have greater autonomy than non-foundation trusts and are encouraged to operate as businesses. Payment by resuts was introduced in 2002 to promote competition, aowing ow-cost providers to retain surpuses. Cinica services are now organised as autonomous business units within the business, which invoves cinica staff in activity reviews, costing and budgeting, service improvement and deveoping business pans. The House of Commons Heath Committee 80 concuded that the foundation trust appication process had forced NHS organisations to operate in a more business-ike way (p. 36). Commercia practices such as process redesign, quaity improvement and ean have become common practice across the service. 81 83 The private sector now pays a key roe in pubic sector services. 84 The pubic services industry (PSI) invoves private and third sector businesses providing services under government contract. The PSI in Britain empoys 1.2 miion peope, generating annua revenues of around 80B, covering services such as maintenance and ceaning, computing and other business processes, socia care faciities, services for the edery, chidren and peope with disabiities, custodia services, eisure services, waste management, and cinica care provided by independent treatment centres. Heath is the argest component of government spending on the PSI, totaing 24B in 2007 8, foowed by socia protection ( 18B), defence ( 10B) and education ( 7B). The Juius review 84 concuded that subjecting providers to competition reduces costs without affecting quaity, and advised that pubic service markets shoud be exposed to further competition. The UK has severa private heath-care providers and insurance companies, with a market vaue of 6.1B in 2009 10. The second argest source of income for private providers, after medica cover, is the NHS, which accounts for one-quarter of the private sector's income. 85 The private company Circe was the first to be contracted to run a NHS hospita from 2012. In 2011, NHS Wirra became the first hospita to give expectant mothers the choice of either a NHS midwife or one empoyed by a private company. 86 From 2012, foundation trusts can earn up to haf of their income from private work. 87 The NHS earns around 0.5B per annum treating private patients in NHS faciities; 1.6B was paid to doctors for private work in 2009. Britne 88 argues that a more entrepreneuria NHS coud make money for Britain by exporting construction and project management services, primary care expertise, education and training, heath data management innovations and medica faciities to China, the Midde East and Africa, generating 50B in annua revenues. These trends suggest that a commercia mindset is required, to embrace new business modes and strategies, organisationa and manageria innovations, inventive uses of staff resources and new technoogies, pubic private sector coaborations and ways to invove patients in care management. The governance dimension Nationa governance arrangements may seem remote from hospita management; however, these arrangements shape the expectations and demands paced on management and other staff, determine their goas and priorities and define the various other organisations with which acute trusts interact. Pariament has overa responsibiity for the service. The Secretary of State for Heath is assisted by five other heath ministers, and oversight is conducted through three seect committees, for heath, pubic accounts and pubic administration. With an annua budget of 214M and 2200 staff, the Department of Heath is responsibe for strategic eadership and for achieving better heath and we-being, better and safer care and better vaue for money. The department has three senior staff: permanent secretary (day-to-day running of the department), chief executive of the NHS (heath service management and performance) and chief medica officer (medica adviser and professiona head of medica staff in Engand). In addition to a departmenta board (strategy) and a corporate management board (eadership and business panning), the NHS operations board oversees the day-to-day running of the service and the annua operating framework. The department aso managed 20 arm's-ength bodies, responsibe for reguation, estabishing standards and centra services. A review in 2010 proposed to reduce their number to 10 by 2015. 89 24 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 The White Paper in 2010 1 set out a 5-year strategy, repacing the 5-year pan, From Good to Great, (2010 15), deveoped by the previous administration. 90 Promising to reduce micromanagement, the White Paper emphasised giving power to patients and cinicians. Poicy thus concerned iberating the NHS, removing ayers of bureaucracy, encouraging foundation trust autonomy and empowering the front ine. The reguatory regime was to be strengthened. The CQC was to operate a joint icensing scheme with Monitor. The White Paper aso promised an NHS information revoution, providing access to information on conditions, treatments, safety, effectiveness, ifestye choices, outcomes, patient experience and nationa cinica audit information. Heathwatch Engand, a new consumer champion body, was to advise other nationa bodies, and aert the CQC to concerns about quaity of services. The new commissioning board woud empoy 3500 staff with a budget of 20B for direct commissioning. Noting that reorganisations can have dysfunctiona consequences, Edwards 91 ists 69 changes in the NHS between 1974 and 2009, an average of two a year. Assessing these reforms, he comments: This is ike the teevision programme Scrap Heap Chaenge where contestants have to construct compex projects out of a variety of different parts that don't fit together, were intended for another purpose and may be broken. Poicies and incentives need bending, boting together or otherwise adapting to make the oca system work. But this is not an easy task. The definition of the right thing is often contested and the incentives and accountabiities are designed so that organisations, or departments have to ook after their own interests. An optima goa for a oca system cannot be achieved by each of the participants trying to optimise their own position. p. 17 91 It is difficut to see, in this most recent reorganisation from 2010 onwards, the oosening of centra contro, reaxation of reguation or simpification of bureaucracy. The governance of the NHS is characterised by centra command, compexity, bureaucracy, hierarchy and reguatory oversight, with contro exercised through 5-year pans and annua operating frameworks. The reguatory dimension I've been inspected recenty by the SHA [strategic heath authority], OFSTED [Office for Standards in Education, Chidren s Services and Skis], LINks [Loca Invovement Networks], CQC, HOSC [Heath Overview and Scrutiny Committee], HSE [Heath and Safety Executive]. They a have different requirements, which overap, but they have different parameters. And they a want information, reports, and action pans, which can contradict each other. And in a these bodies, I've yet to meet anyone who is an expert in heath or emergency care. They' ask about ca bes in the toiets, and response times, and how often foors are ceaned. Nobody ever asks me how many ives we've saved, or how many peope got better as a resut of the treatment they received. I spend a ot of my time writing poicies. Lead nurse, Greenhi NHS reguatory bodies have proiferated. This is frustrating when different bodies ask for simiar information, and demotivating when the activity has no impact on the provision or improvement of patient care. Reguation in Engand appears to have reduced waiting times in comparison with Scotand. 92 Edwards and Lewis 93 concude that changes in reguation have encouraged a more businessike approach and have aso strengthened the focus on quaity of patient care and safety. Nevertheess, a review by the NHS Confederation 94 noted the aarming overap across 35 RAIAs in their focus on around 900 standards. Among those RAIAs, two bodies are key: Monitor and the CQC. Monitor Since 2004, Monitor has been the foundation trust reguator, responsibe for estabishing terms of authorisation and issuing icences. 95 In 2010 11, Monitor had 150 staff, with an annua budget of 15M, which was expected to rise to 50M as it assumed new sector reguator powers from 2013. A providers of Queen's Printer and Controer of HMSO 2013. 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. 25

THE INSTITUTIONAL CONTEXT NHS services must now have a joint icence from Monitor and the CQC. Monitor's roes are to ensure financia viabiity and good governance. Assessment covers meeting nationa targets and standards, board roes and structures, monitoring of cinica quaity and whether or not the trust is meeting its terms of authorisation. Trusts must provide annua pans, quartery in-year submissions and exception reports. If a trust is found to be in breach, scrutiny becomes more intensive, eading to intervention in the case of a significant breach. Care Quaity Commission Since 2009, the CQC has reguated the quaity and safety of care in reation to nationa government standards. The CQC aso registers providers who have to adhere to a compiance framework 96,97 and meet the essentia standards of quaity and safety set out in a 270-page document. 98 The CQC maintains a Quaity and Risk Profie for each registered provider. It aso operates an inspection regime, which has been controversia, particuary in faiing to identify instances of poor-quaity care that were ater exposed through other routes. The CQC can aunch responsive reviews if concerns are raised about quaity and safety of care, with an enforcement poicy that incudes warning notices, penaties, cautions and utimatey prosecution. The CQC has 2000 staff, and an annua budget of 140M, and in 2011 reguated 21,000 providers operating services from over 36,000 ocations. The operating framework for 2010 11 99 reaxed the transit time trigger for patients attending emergency departments, from 98% to 95% (of patients to be seen within a maximum of 4 hours). The maximum 18-week wait referra to treatment (RTT) target was dropped, but the framework indicated that commissioners shoud retain the RTT target in their contracts, and that median waiting times shoud be used as an additiona measure. The Nationa Cinica Director for Urgent and Emergency Care subsequenty introduced in December 2010 eight new indicators on which emergency departments were to be assessed. In June 2011, the NHS Director of Performance announced that the 4-hour transit time target woud continue to be performance managed after a, aong with a of the new emergency department quaity indicators. The revised NHS Outcomes Framework for 2012 13 100 proposed one framework, five domains, 12 overarching indicators, 27 improvement areas and 60 indicators in tota (p. 16). In December 2011, the Department of Heath 101 aso decided to bring about a major shift in cuture within the NHS, and deveop our peope by hard wiring innovation into training and education for managers and cinicians (p. 13). This report identified six innovations for trusts to adopt. The change in cuture was to be driven by standardised efficiency measures and by fining providers and commissioners who did not impement Nationa Institute for Heath and Cinica Exceence (NICE) rues on best practice, in addition to a new centra management compiance regime supported by an Impementation Board with task and finish groups that woud ead changes in individua areas. Senior managers themseves may become subject to reguation, arising from the pubic inquiry into Mid Staffs. 70 An advisory group has made recommendations incuding a statement of professiona conduct, competency standards, strengthened appraisas and a professiona accreditation scheme. 102 The Counci for Heathcare Reguatory Exceence has produced a draft of the ethica, behavioura and technica standards that managers are expected to demonstrate. 103 The finance dimension Every conversation about every activity it's probaby no exaggeration and et's take training as an exampe, aways begins with the question, who's going to pay? Not how does this benefit the organisation?, what's the need of the peope working for us, and how does this fit with our objectives or our patients? It's aways about, who pays, where's the money coming from. Assistant director, Netherby 26 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 The NHS had been in deficit in 2006 but improved financia management produced a surpus by 2007 8. The operating framework for 2008 9 noted that, as financia difficuties were resoved, the service coud focus attention on infection contro, access, better heath, inequaities, improving patient experience and staff satisfaction and emergency preparedness. 104 However, the impact of the NHS recession became cear in 2009. By 2011, one commentator predicted a funding ice age asting at east unti 2015. 105 The funding mode has become increasingy compex and is subject to constant change as financia incentives and penaties are adjusted to encourage or discourage particuar behaviours and activities. The core of the funding mode is a payment by resuts system designed to ensure that funding foows patients, reinforcing the poicy of patient choice. The main component of NHS spend (around 60%) provides for acute care. Acute trusts are thus paid for the activity that they undertake. Accuratey recording and coding that activity is centra to determining trust income. From 2010 11, trusts were expected to make annua savings of 3.5%. For an acute trust with an annua turnover of 400M, that meant finding 14M in recurring annua savings. Sma changes to the nationa funding mode can thus have significant impications at oca provider eve. A survey of finance directors in 2010 found that, as we as recruitment freezes, 58% of finance directors in acute trusts predicted cuts in administrative and junior management roes, and 50% said that they expected the numbers of senior managers in their trust to fa. 106 In March 2011 the Heath Service Journa pubished onine the resuts of a survey of 279 chairpersons and chief executives, who reported that cutting costs and baancing their budgets was now their biggest chaenge. The NHS operating framework for 2012 13 introduced a further 1.5% reduction in tariff (having been cut by that amount in the previous year), in addition to seeking 4% efficiency savings, and expressed the aim to drive the 20B savings programme further and faster, introducing penaties for poory performing providers and for faiures to provide accurate data. 107 Pressures on acute trusts from 2011 were substantiay increased, eading providers to respond that these cost pressures were not sustainabe and coud resut in unsafe working practices, and that the acute sector in 2012 13 was facing a perfect storm. 108 By mid-2011 it appeared that many acute trusts were missing the efficiency targets in their CIPs by significant margins. In addition, some trusts had made savings that were not recurrent, and increased emergency activity meant abandoning pans to cose beds in some trusts. 109 Figures for the trusts participating in this project are shown in Tabe 12. The media dimension Managers are the jam in the sandwich. They don't ike the negative stereotype. It's about the management of reputation. The NHS itsef is not doing anything to curb i feeing towards management. Even on Hoby City [popuar teevision programme] the manager is the bad guy; managers are the owest of the ow. Operations manager, Cearview TABLE 12 Participating trusts' CIPs, 2010 11 Trust Turnover 2010 11 Target CIP Actua CIP (%) Burnside 145M 4.96M 3.67M (76) Cearview 592M 35M 33M (94) Greenhi 422M 30M 30M (100) Netherby 236M 10.4M 10.52M (101) South Netey 450M 24M 28M (117) Watte Park 244M 13.8M 15M (109) Queen's Printer and Controer of HMSO 2013. 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. 27

THE INSTITUTIONAL CONTEXT The NHS operates in a godfish bow of media scrutiny (p. 25). 42 Media reporting infuences pubic perceptions of the service, and of its management and staff. For instance, in January 2012, the Heath Service Journa reported the case of a London trust where the number of compaints had doubed over 9 months. An interna board report attributed this increase to adverse media coverage of the quaity of care at the trust, the impication being that bad news had sensitised the pubic to these issues and predisposed more patients to compain. By focusing on bad news, the media reinforce the view that the NHS is faiing, and that its managers are costy bureaucrats. The press are in business to attract readers and make money. Davies 110 sets out the rues of production that shape the nature of reporting to achieve those ends: run cheap stories quick and safe to cover, no compex or contentious investigations seect safe facts which can be attributed to officia sources (spokespeope, reports) avoid the eectric fence defer to anyone with power to do you damage seect safe ideas use mora and poitica vaues and assumptions that are widey supported aways give both sides of the story give baance if you have to report something unsafe print what they want stories that increase readership if we can se it, we' te it simpify avoid context and sow-burning taes in favour of short dramatic events print what they want to beieve stories that are consistent with readers' vaues go with the mora panic in a crisis, se the readership a heightened version of its own emotiona state in the crudest possibe form (p. 142) ninja turte syndrome run stories that are widey reported esewhere, even if they ack merit (parents who prevented their chidren from watching the teevision series found themseves and their chidren isoated). Hospitas that are meeting performance targets with baanced budgets, satisfied patients and capabe staff are not good sources of sensationa stories. Faiures, crises, accidents, misconduct, mistreatment of patients and financia difficuties are more interesting. Sady, the press and media in the UK do not have to work hard to find exampes of the atter. Foowing those rues of production, NHS managers get a bad press, athough uncaring nurses and unreguated heath-care assistants are not immune. The King's Fund report on eadership and management in the NHS began by observing that, whenever poiticians tak about management it is amost invariaby a pejorative term. It is often equated sneeringy with bureaucracy (p. 1). 42 One opposition heath spokesman spoke of the increasing number of men in grey suits and a heath minister derided primary care managers as pen-pushers (p. 1). 42 The chairperson of the government's Future Forum on the NHS argued that the government shoud stop sagging off managers (p. 9). 111 The King's Fund commission aso observed that the negative stereotype was an insut to managers, and to cinica staff in manageria roes, arguing that cinicians are thus discouraged from taking on these roes. 42 In this atter respect, government ministeria rhetoric was seriousy undermining the poicy of encouraging greater cinica engagement in heath-care management. The managers participating in this project were nevertheess committed to the service, and most (but not a) were more than happy to acknowedge their manageria responsibiities in research interviews and focus group discussions. However, many chose not to describe themseves as managers in pubic, and one observed that being abeed as a midde manager was incrediby degrading. The management diemma The features of the institutiona context of NHS management work are summarised in Tabe 13. 28 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 13 Dimensions of the institutiona context: shaping norms, vaues, expectations, structures, processes, behaviours History Features of the ( accessorised ) professiona bureaucracy persist Hierarchica, centray funded, centray controed Constant reviews and disruptive reorganisations The egacy of high-profie faiures is a burdensome reguatory regime Goba financia crisis ongoing need to cut costs, find efficiencies Business Pubic and private heath-care sectors are now cosey intertwined Cinica services are structured and run as independent business streams Need to adopt an entrepreneuria, commercia mindset Must baance profitabiity with quaity and safety of patient care Expected to generate revenue from innovation and exports Governance New government introduces compex, rapid, controversia reorganisation Powerfu new centra commissioning board Primary care to be responsibe for 80B annua spending The poicy of cutting management costs generates resentment Difficut to see the promised autonomy, empowerment and iberation Reguation Many reguatory bodies (RAIAS), create significant administrative burden Reguation has improved some aspects of performance Reguation has not prevented serious care faiures Support for innovation comes with penaties and a compiance framework Reguation of managers expected from 2013 Finance NHS recession, funding ice age, perfect storm The Nichoson chaenge find 20B of savings Cutting costs reorganising increasing activity Uncertainties and anxieties over job security Need to baance savings with quaity and safety of care Media Rues of production produce sensationay bad news Media stories infuence pubic perceptions and government poicy Managers are typicay bamed for probems and faiures Commentary supportive of heath-care management is rare The negative stereotype pen-pushing bureaucrats prevais At the heart of this anaysis sits a management diemma. Providers are encouraged to operate as commercia enterprises, and to be entrepreneuria, innovative and revenue generating. But they are expected to do this in the face of a burdensome reguatory regime in which faiure to compy with centra contros can ead to financia penaties and senior staff job osses. This has not deterred many significant innovations. But this diemma may be an insurmountabe barrier to the disruptive innovation that may be required by a traditiona service in a rapidy changing word. 112 Queen's Printer and Controer of HMSO 2013. 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. 29

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Chapter 4 The organisationa context The ong to do ist This chapter expores how the oca organisationa context shapes the nature of management work. First, the six acute trusts are profied. Second, the impications of service-ine management structures are considered. Third, the management agendas of two trusts are described. Finay, the impications for midde management are expored. The anaysis of the institutiona context in Chapter 3 exposed a tension between innovation and compiance. This chapter exposes a further tension, between poicy to reduce management numbers and adding to management agendas. Information for this chapter comes from trust websites, other hospita information and set-up interviews. The concusions are: these are arge, compex organisations, often one of the argest empoyers in their oca area, some with histories reaching back to the 18th and 19th centuries most have egacy issues reated to od buidings and computer systems, with the atter frequenty being incompatibe with one another and inadequatey specified to provide appropriate and timey business information cinica directorate structures, dating from the 1980s, were being repaced by service-ine management, with divisions run as businesses within a business, bringing autonomy, transparency and accountabiity, but encouraging sio working, discouraging information sharing, generating insecurity and creating a ack of carity with regard to accountabiity the scae of the financia and operationa chaenges was such that three trusts fet that it necessary to recruit externa management consutancy support for their transformation programmes those chaenges focused attention on organisation cuture and on eadership and management skis and styes acute trust management agendas are ong and compex, with most issues invoving significant organisationa change midde managers are subjected to mutioading (deaing with many different activities) and perpetua oading (working at capacity, aways economising), the standard responses to which (hat ess essentia activity, focus on a sma number of key issues) are not avaiabe capacity (see Chapter 2) is a critica management issue, and a priority for further research. Trust profies To indicate the scae and compexity of the trusts participating in this study, and the scope of the hospita management task, Tabes 14 and 15 profie the attributes of the two foundation and four non-foundation trusts respectivey. Cearview Estabished in the 18th century, Cearview moved to its current site in the 1960s. At the time of this project, this site was doubing in size, with new faciities to support existing services, provide new deveopment opportunities and accommodate a speciaist cardiothoracic hospita. Cearview was aso the regiona major trauma centre, had an internationa reputation for teaching and research and was one of the argest oca empoyers. Between 2007 and 2009, most of the top team changed, and the average tenure of executive directors at December 2009 was 3 years. Cearview had a 40M deficit for 2011 12, with activity eves outstripping funding, and with a need to work cosey with commissioners. Meeting most performance targets, Cearview decared non-compiance with the emergency department transit time target in the fina quarter of 2011 12, and did not meet the 62-day Queen's Printer and Controer of HMSO 2013. 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. 31

THE ORGANISATIONAL CONTEXT TABLE 14 Attributes of Cearview and Greenhi Attributes Cearview Greenhi Income 2010 11 577M 430M Popuation served 500,000 612,000 Outpatient visits 460,000 430,000 Day cases 116,000 74,000 Emergency attendances 93,500 105,000 Non-eective admissions NA 62,000 Eective admissions 67,800 (tota) 18,000 Staff 7100 8000 Beds 1000 600 Wards 40 52 Sites 1 2 NA, not avaiabe. TABLE 15 Attributes of Burnside, Netherby, South Netey and Watte Park Attributes Burnside Netherby South Netey Watte Park Income 2010 11 121.2M 230M 495M 244M Popuation 270,000 880,000 900,000 480,000 Emergency attendances 66,000 80,000 90,000 95,000 Eective admissions 23,500 50,000 21,000 81,000 Non-eective admissions 22,000 40,000 59,000 30,000 Staff 2100 4200 9500 3400 Beds 400 600 1100 650 Wards 19 30 95 24 Sites 2 2 2 1 target for cancer patients in three out of four quarters, decaring amber-red for governance. There were constant pressures on beds. Budget cuts incuded a vacancy freeze. The divisiona structure estabished in 2009 created autonomous business units, but as divisiona directors acked manageria capabiities divisions were sti subject to top team intervention. The IT infrastructure comprised a hundred separate systems which were not inked to each other (assistant director operations). A new business inteigence system was designed to overcome this probem, with a performance dashboard providing information on sickness, absenteeism and mandatory training making those aspects of staff management easier. An ehospita was being panned. Greenhi Aso estabished in the 18th century, Greenhi moved in 1960 to its current site where, in the 1940s, wooden huts had been erected to treat war wounded. Greenhi merged again in 2002 with another hospita and was the second argest empoyer in the area. A service-ine management structure was introduced in 2009, with each of the four cinica divisions managed by a triumvirate incuding chief of service, divisiona nursing 32 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 director and divisiona director of service deivery. The average tenure of executive directors at December 2009 was 3 years. In 2009 10, Greenhi saved 24M, and panned savings of 30M for 2010 11 were achieved. The operating framework requirements of December 2011 meant that a further 18M savings had to be found, invoving the potentia oss of severa hundred posts. In 2009, Greenhi faied to meet emergency department targets and decided to redesign radicay the care of emergency patients. Greenhi had an ambitious organisation deveopment programme, aunched in 2007 and driven by an organisation deveopment task group, to deveop a high-performing organisation. The trust had its own eadership deveopment framework. Objectives for 2011 12 were to generate a surpus of 0.5% for reinvestment, achieve a financia risk rating of 4, deveop service-ine management and patient-eve costing and deveop a pan for the optima distribution of services across the two sites. This ast item was an ongoing source of tension, as there was sti a divide between the sites. Burnside Estabished in the eary 19th century, Burnside had 60 departments that were organised in 2011 12 into five cinica business units: women and chidren, acute medicine, speciaty medicine, surgery and cinica support. Activity eves were rising, particuary emergency attendances and non-eective treatment. Staff numbers in 2011 were the same, however, as in 2007. The average tenure of executive directors at December 2009 was 3.5 years. Management at the time of this study faced severa issues. The foundation status bid was paused by Monitor in 2009 for financia reasons. The trust had a CIP, supported by externa management consutants, to save 24M over 2 years to 2013 14. Burnside was aso invoved in a regiona acute services review designed to improve efficiencies across five hospitas. The workforce was oca and stabe, but with some recruitment difficuties, and the commitment of consutants to the trust was questioned. Some performance targets were not being met canceations, recas, waiting times and maintaining care quaity with financia constraints was perceived to be difficut. Reationships with commissioners were poor because of disagreements over funding. A ean programme was aunched in 2008, to find efficiencies and generate savings. Wecomed by most staff, but resisted by sippery pigs and dinosaurs, this programme generated 6M in savings. Burnside was seen as a hospita that was busy being busy, without time for refection. Netherby Netherby's history dated from the 18th century, some of the origina buidings were sti in use and the hospita aunched a modernisation programme from 2008. A teaching hospita, Netherby was aso a designated cancer centre, operated a sateite day surgery service at a community hospita and was the regiona designated primary stroke centre. It was one of the argest oca empoyers but had recruitment probems. Athough staff turnover was ow, this meant no new bood and maintained a famiy atmosphere with a no-chaenge cuture. Netherby had five chief executives during this project. The average tenure of executive directors at December 2009 (excuding one particuary ong-serving director) was 2 years. Management chaenges incuded the ageing estate and rising eves of non-eective activity. The pressure on beds was constant, but a reduction in bed numbers to 500 was panned for 2012. A deficit of 30M was forecast for 2013 14 and a transformation programme was aunched supported by externa management consutants who estabished reviews of services based on profitabiity. The service improvement team had much success with ean projects, improving care quaity and saving time, but came under pressure to reduce costs. The workstreams of the transformation programme expored ength of stay, outpatient department productivity, administration and secretaria processes, and staffing. Management posts, back office functions and corporate services were aso reviewed in 2011. An overa reduction in posts by around 600 was expected, and a service-ine management structure woud reduce the number of directorates, and cut management ayers, numbers and costs. Queen's Printer and Controer of HMSO 2013. 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. 33

THE ORGANISATIONAL CONTEXT South Netey The headquarters site at South Netey opened in the 1920s as a tubercuosis hospita and expanded during the Second Word War in the expectation of high casuaty rates from bombing. Many wartime buidings were sti in use at the time of this project. South Netey's second site was opened in the eary 20th century as a workhouse, was used as an army hospita during the First Word War and a new hospita was buit on the expanded site in the 1920s. South Netey was buiding a 430M state of the art hospita on its second site, due to open in 2014, with the headquarters site becoming a community hospita. Funding the new buid put the foundation trust bid on hod unti 2012. The average tenure of executive directors in post in December 2009 was 5 years, making this the most stabe board of the six trusts participating in this study. One chaenge was to deveop new hospita working, with new practices, cuture, behaviours, systems and structures. The hospita was consistenty meeting performance targets and had among the owest mortaity rates in the country. Nevertheess, South Netey aso had to make savings of 28M in 2011 12. Financia targets had been met since 2006 7, but reationships with commissioners were described as a batte and fraught. Senior management regarded the resuts of the 2010 annua staff survey as disappointing, with ow scores concerning satisfaction with quaity of patient care that staff were abe to deiver, pressures of work and stress. Staff engagement was thus a priority. South Netey had deveoped its own eadership deveopment programme aiming to adopt a more business orientated way of thinking and working. This programme was designed for the 172 mission critica eaders and woud eventuay cover the top 600 staff. This programme focused on five core eadership behaviours : understanding and managing context, working in partnership to drive improvement, tacking difficut issues, empowering others and emotiona inteigence. Watte Park Formery a 19th-century workhouse, Watte Park was estabished on its current site after the First Word War, inheriting a coection of edery buidings. Because of financia pressures, the trust was discussing a merger with two other hospitas, which was agreed in December 2011. An independent bid for foundation status was abandoned and redeveopment pans were deferred. There was ony one change of chief executive during this project, but the hospita had a history of instabiity at board eve, and trust between the top team and midde management had been weakened. The average tenure of executive directors in post at December 2009 was 2 years. In 2006, Watte Park had a deficit of 40M and aunched a turnaround programme. Financia probems persisted, however, contributing to the urgency of merger discussions, with savings of 14M required in 2011 12. In October 2011, considering extraordinary financia measures, staff were asked to sacrifice part of their annua eave, take unpaid eave or perform additiona unpaid sessiona duties. The executive team gave up 2 days' hoiday entitement. At the end of 2011, the Department of Heath designated Watte Park as financiay unsustainabe and further savings of 28M were to be achieved by March 2012. Senior staff fet that management competency gaps were not addressed, as training and deveopment budgets were frozen aong with cuts in midde management posts, which had weakened management capacity. IT systems were seen as unabe to provide appropriate management information. Watte Park was we rated by the CQC but a review in 2011 raised concerns about ceaniness, infection contro and staffing eves. The use of ean methods had been successfu, and a patient experience revoution beginning with in your shoes workshops invoved over 5000 patients and staff in deveoping quaity initiatives. A staff were given customer service training and nurse-ed houry rounding on wards was introduced. Watte Park aso had to dea with a high voume of referras, weak demand management, a growing and ageing oca popuation and attempts to move care into the community that were probematic because of a ack of faciities and because anticipated savings did not materiaise. A senior manager said, So we're eft with a very difficut management agenda, in terms of trying to baance a these priorities. 34 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Changing structures The reguator, Monitor, was encouraging estabished and aspiring foundation trusts to adopt service-ine management methods, 113 and hospitas were introducing new organisation structures, with new management roes and responsibiities. This invoved estabishing autonomous cinica divisions operating businesses within a business, with cinica staff taking the ead on service deveopment. Each business unit thus had ceary identified resources, incuding staff and support services. In 2009, for exampe, Netherby had a traditiona cinica directorate structure, with a separate management team for each of the 18 directorates. The 10 cinica directorates were each managed by a triumvirate incuding a cinica director, directorate manager and head nurse. An externa management consutant working with Netherby in 2011 was asked about the strengths of this structure: I'm strugging to think of any strengths of the current organisation. Managers seem to be dedicated and the pay is good. Turning to weaknesses, he observed: The hierarchies are too deep. There are no cear ines of responsibiity and accountabiity. The information to inform decisions is poor. Business cases are based on seective information. There's a ot of fag waving around cinica standards and patient safety. One-third of the staff are in the administrative and secretaria category. How much energy do we need in those areas? There's a ot of bureaucracy. We need to understand non-vaue-adding activities. What are the consequences of not doing some of these things? Do we know how much this is costing? At the moment it's a anecdota; we need evidence. We're short of change agents who possess Rottweier tenacity. And there's too much poitics. One director observed that issues were passed up the tree and escaated unnecessariy. Accountabiity and performance management were acking. There were too many directorate managers and management ayers, and structures were not consistent across services. In 2011, Netherby introduced a service-ine management structure. Two care groups medicine and surgery were created, each with a group director, ead nurse and two genera managers. The cinica directors became medica service eads, each supported by a service manager. This management reorganisation woud generate savings of between 2M and 3M per annum. For Monitor, the benefits of this approach incuded the empowerment of cinicians, efficiency and productivity, oca ownership of budgets, seeing the big picture and accurate patient-eve costing. According to matrons at Greenhi, however, these structures were probematic. Greenhi introduced a service-ine structure just before this project began, and the matrons argued that the new independent divisions had entrenched the trust's sio mentaity. An operations manager at Cearview described the now hostie resource discussions between their divisions as Reservoir Dogs moments (from the movie in which eading characters threateningy point their guns at each other). The Greenhi matrons argued that divisiona sios had other probems: We used to know what was going on in the other areas or divisions. And we used to share good practice. But not now. As modern matrons, we have to take on the roe of duty ead nurse (DLN) once or twice a week. This invoves a shift from seven in the morning unti three in the afternoon. And we aso do this once a month on a weekend. The nature of this roe hasn't changed much, but we are now being asked to do this more often. As the organisation structure has become more sio based, this means that we don't have such a good understanding of what happens in other areas as we did before. So that makes the DLN roe more difficut because you're aways having to ask about things, to get the information. Queen's Printer and Controer of HMSO 2013. 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. 35

THE ORGANISATIONAL CONTEXT If duty nurses do not fuy understand the issues they face, and spend time gathering information, this may adversey affect the quaity and safety of care. The advantages and drawbacks of service-ine management structures in acute settings have not been we researched. Management agendas A centra feature of the organisationa context concerns the nature of the agendas that management had to dea with. In set-up interviews, midde and senior managers were asked to identify the main issues on the management agendas of their trusts. Given space constraints, this section expores the agendas of two trusts, Netherby and Greenhi: one foundation, the other not. The Netherby management agenda At Netherby, a picture of the management agenda was constructed from the responses of 17 managers, incuding four board members, seven hybrids and six managers. They identified 86 items, which were content anaysed to identify themes. This reveaed an agenda with 16 main themes and two other issues concerning uncertainty and competing priorities. Many of the main items were inter-reated, but their separation serves an anaytica purpose in estabishing an overview of the nature of the agenda. Content anaysis assumes that an issue that is mentioned more frequenty may be more significant than those which are mentioned infrequenty. However, that is not necessariy the case, and Tabe 16 does not indicate reative priorities. Management attention to communications and serious incidents can be as strategicay significant as that to targets and finance. Of the two other items the first concerned competing priorities, based on comments such as it's increasingy difficut to strike a baance across these different demands, baancing the budget whie improving productivity and effectiveness, patient experience, safety; managing these mutipe demands is tricky. The second concerned uncertainty, based on comments such as the uncertainty that we are facing, managers are working in an extremey uncertain and unstabe environment and how to construct a sustainabe 5-year pan in this context?. Thus, this management agenda had five properties: 1. ength: this is a big to do ist 2. compexity: the items are individuay compex and they are intertwined 3. strategic: a of these issues are strategic, in terms of contribution to ong-term performance and surviva, and they are a aways important 4. change: a of these items invove significant ongoing organisationa changes 5. typica: this ist refects who we spoke to and when; a different sampe at a different time woud produce a different resut, but we woud nevertheess expect to see a simiar pattern, and we do see this at other participating sites. Tabe 16 is based on information from 2009 10. Were this question to be revisited in 2015, say, a different set of items woud probaby emerge. However, given the continuities in the institutiona context (see Chapter 3), it is highy ikey that, athough specific themes may become more or ess saient, those properties of the acute trust management agenda are reativey durabe. The Greenhi management agenda Content anaysis of repies to the management agenda question at Greenhi is shown in Tabe 17, based on responses from 12 participants, incuding two board members, four hybrids and six managers, who identified 57 agenda items, coded under nine theme headings and a reguation and other issues category. This dispays the same items and properties as the Netherby agenda engthy, compex, strategic and change orientated. 36 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 16 Netherby management agenda: 2010 Item (count) Substance Iustration Targets (17) Mutipe targets, distraction Targets hundreds of them; easy to get distracted from the daiy running of the trust Finance (12) Reationships (9) Change (8) Activity (6) Reguation (6) Find savings, generate income, increase productivity PCT, other hospitas, community heath, ambuance service Changes to cuture, structure, work practice Growth in demand, winter pressures Workoad invoved in responding to guideines It's an obsession every conversation is about money, need to increase productivity; we've impemented ean; where do we find another 0.75M this year? Coaboration is difficut; competition is the norm; we need to work with our PCT to make sure that systems and processes are in pace in the community Need to work differenty; change the cuture from apathy to one in which peope take responsibiity; too many directorates Voume of work is increasing; 20% rise in one area with the same team; capacity and demand for next winter Monitor and CQC compiance; increasing burden of reguation; the pressures are getting stronger; the governance agenda is massive Faciities (5) Buidings, ayouts, space Ageing estate; need to ensure that patients fee comfortabe and safe; the environment has to be right; financia restrictions mean that it wi be chaenging to maintain standards Information systems (4) Cinica engagement (3) Business orientation (3) IT infrastructure, cinica and manageria information Nationa poicy for cinica eadership Deveopment of a more commercia approach Inadequate IT; we need good market information and interna costing and management systems; chaenge is to deveop ive information on activity and costs Cinica directors don't see themseves as eaders; cinica engagement; we must get it right, get key payers on board We need to be more business orientated; we've got to run as a business now; we need to earn better how to compete Management changes (3) Top team instabiity Lack of job stabiity among senior management; changes to our senior team have been destabiising Leadership deveopment (3) Patient and pubic expectations (2) Leadership and management skis PPI agenda Assessment centres and persona deveopment for directorate managers; training for those in eadership roes Managing pubic expectations; the pressure to do other things means that there's a danger we ose patient focus HR issues (2) Turnover, deveopment Low staff turnover has advantages but it means no new bood ; staff deveopment once in post Learning from SUIs (2) Communications (1) Learning in genera and foowing Mid Staffs Information fow down the organisation We have experienced SUIs, which have been subject to SHA investigation; pressure foowing Mid Staffs Managers don't pass on information; sister said, I don't know where the chief executive's office is HR, human resources; PPI, Patient and Pubic Invovement; SHA, strategic heath authority; SUI, serious untoward incident. Much doing to be done If NHS managers are strugging it is because of the size of the agenda and the ack of respect for the management task invoved; and the systematic ack of investment in earning it is hard to earn together when there is so much doing to be done. p. 19 114 Queen's Printer and Controer of HMSO 2013. 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. 37

THE ORGANISATIONAL CONTEXT TABLE 17 Greenhi management agenda: 2010 Item (count) Substance Iustrative quotes Finance (11) Change (11) New environment; find savings, ess resource, increasing demand Improvement, redesign, earning from SUIs, change cuture and stye The trust historicay is not good at saving money; we're expecting a cut of 60M over the next 3 years; this is the hardest we've ever faced We want to insti continuous improvement; redesign, productivity, right first time; how do we get rea change?; how do we get earning from incidents and compaints? Targets (9) RTT, quaity, safety, A&E waits Priority to make services safe and high quaity; financia constraints; we have not met the transit time target for 2 years; why crunch numbers to make government ook good Cinica engagement (6) Activity (5) Staff engagement (4) Staffing (3) Reationships (3) Patient and pubic expectations (3) Reguation and other issues (2) Stye, cuture, cinica eadership, teamwork, deveopment Rising workoad, same staff, productivity, increasing pace of care Communication issues; ack of corporate perspective; need to deveop teamwork Shortages in some areas; recruitment and retention probems Chaenging reations with PCT, SHA, Monitor Increasing pubic expectations Burden of bureaucracy, accreditation demands, risk management Who eads and manages the divisions that's confused; medica eadership is a chaenge; management got resuts by pushing harder, not by changing anything; engaging doctors might be right, but we don't want to disengage managers Increasing eves of activity is a key issue; we need to improve productivity; worrying increase in emergency admissions; meeting standards with an increasing workoad We're not good at engaging peope in soutions; I'm not sure our doctors are engaged with the trust; some can and won't, some can't, others are wiing and fexibe; chaenge to use the skis and knowedge we have in teams We do not have idea staff eves in midwifery; difficuties in paediatrics too; quaified chidren's nurses are scarce; not enough emergency department consutants Reationships with PCT inhibit change; to achieve savings radica changes rather than margina improvements are required; cimate of mistrust; PCT is a buy; word-cass commissioning means being a stronger buy Rising patient expectations of the NHS; doing what patients want and not what we want to do; being accountabe to the pubic and staff but without being punitive More expicit bureaucracy; reguatory demands, need to register with CQC; three suicides over 8 months questions around safe management of sef-harm patients A&E, accident and emergency; SHA, strategic heath authority; SUI, serious untoward incident. What are the management impications of this anaysis of organisationa context and management agendas? From an operationa management perspective, there is a daiy chaenge to match patient demand with cinica, physica and financia resources. Patient numbers are high and unpredictabe, and reduced ength of stay means that patient fows are faster paced. Demand has increased in many services whie resources have been cut. Management has aso had to address radica changes fowing from nationa, regiona and oca reorganisations, higher pubic expectations, an increasingy burdensome reguatory regime and the need to reduce costs, year on year, potentiay affecting job security. In this context it is not possibe to focus on, say, two or three issues in 1 year and on another set of issues the next. This is an agenda on which a of the items 38 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 are aways priorities, which compete with each other for attention and resources, and which change frequenty. From research in commercia organisations, Bruch and Menges 115 describe a simiar pattern: increasing market pressures and speed of activities, raised performance goas, new technoogies and systems and attempts to make this furious pace the new norma (p. 82). This eads to what they ca the acceeration trap, in which focus is scattered, staff are demotivated and customers become confused. In the fuy trapped companies that they studied, 60% of empoyees agreed or strongy agreed that they acked sufficient resources to get their work done. Are NHS managers experiencing a simiar acceeration trap? Our management survey (see Appendix 3) incuded two items reevant to this question. One concerned having sufficient resources (reverse wording from that of Bruch and Menges 115 ) and the other concerned improving the service with fewer resources. Responses to those items are summarised in Tabe 18. The percentage of managers agreeing or strongy agreeing that they possessed sufficient resources ranged from 19% at Netherby to 42% at Greenhi. The % disagree figures are more comparabe with the Bruch Menges question, and range from 66% at Netherby to 38% at Greenhi. Experience of the acceeration trap thus appears to be mixed. However, ony 30% of the whoe sampe agreed or strongy agreed that they had sufficient resources, with 70% disagreeing or neutra. Turning to the second of the items, a more consistent picture emerges. In a five trusts, >90% of respondents agreed or strongy agreed that they were expected to improve the service despite resource cuts. Having to cover many different kinds of activity simutaneousy is what Bruch and Menges 115 ca mutioading. An associated pattern is perpetua oading, in which the organisation operates cose to capacity, drives empoyees hard and deprives them of any hope of retreat: when is the economising going to come to an end? (p. 83). The soutions for breaking out of this trap are to prioritise projects, hat ess important work and carify strategy. They cite the chief executive who aowed managers to name ony three must win battes to focus attention, energy and action. The evidence from this project suggests that many heath-care managers are subjected to mutioading and perpetua oading. The institutiona and organisationa contexts, however, make it difficut to foow the obvious advice. Recent experience suggests, for exampe, that an acute trust focusing its management attention on, say, addressing financia probems and the demands of reguatory bodies may find that ess attention is paid to the quaity and safety of patient care, with disastrous resuts. This appears to have been part of the expanation for events at Mid Staffs. 70,78 TABLE 18 Hospita management and the acceeration trap Burnside Cearview Greenhi Netherby South Netey Question: I have sufficient resources to carry out my management responsibiities effectivey Whoe sampe % agree 39 28 42 19 24 30 % disagree 49 53 38 66 54 52 % disagree and neutra 62 72 58 81 76 70 Question: I am expected to improve the service we provide despite resources being cut % agree 92 92 94 91 95 93 Queen's Printer and Controer of HMSO 2013. 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. 39

THE ORGANISATIONAL CONTEXT A further answer to the probems of mutioading and perpetua oading ies with management capacity. Our evidence indicates that midde managers are highy motivated and deepy committed, but that they are overstretched and under-resourced. Nationa poicy has been to treat heath-care managers as wastefu bureaucrats and to reduce management numbers and costs. This has been accompanied by other poicies, directives and initiatives that have added to the management agendas of acute trusts, stretching capacity even further. Management capacity shoud perhaps be a priority issue for further research. 40 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Chapter 5 The reaities of midde management Introduction One of the main aims of this study was to gain a better understanding of the reaities of midde management work in acute heath-care settings and, in particuar, to understand: the motives and rewards for midde managers the pressures and demands that they face how midde management work is changing. This chapter first reviews pubished research evidence reating to the nature of midde management work in genera and then reviews evidence reating to the nature of midde management work in heath care. The evidence from this study concerning motivation, demands and trends in the nature of management work is then summarised, drawing on survey resuts aong with interviews and focus groups. The main concusions from this anaysis are that: Midde managers in genera hod a wide range of responsibiities, from keeping the show on the road to contributing to strategy, innovation and change, with a profie that sharpy contradicts the pen-pushing bureaucrats imagery. Midde managers, since at east the start of the 21st century, have seen their jobs enarged, their responsibiities widened, the pace and intensity of their work increased, their working hours engthened and their performance monitored more cosey. Managers in heath care face trends and pressures simiar to those affecting midde management esewhere, but aso face the chaenges of driving change in a professiona bureaucracy, deaing with a negative image and a perceived absence of adequate support for hybrids with manageria responsibiities. Surprising survey findings concern the absence of the negative management stereotype (the majority were happy to be seen as managers), the prevaence of extreme job characteristics and ow eves of both job and organisationa satisfaction. Survey findings triggering concern reate to unsustainabe workoads, inadequate resources, poor work ife baance, the sma but significant proportion considering eaving the service and the view that financia pressures have compromised patient safety. The primary motivations and rewards for midde managers incude making a difference, driving innovation and change, doing a good job, feeing vaued, deveoping others, working in high-performing teams, and persona deveopment. A sma number said that rewards were acking, that contributions were not being recognised and that eadership styes were demotivating, and 42% of survey respondents agreed or strongy agreed with the item, I sometimes fee ike eaving this empoyment for good. Many midde managers in heath care appear to have jobs with a profie that can be described as extreme in terms of pace, intensity, scope, conficting priorities, ong working hours and other characteristics a pattern that is exciting and fufiing for some. Extreme jobs are aso associated with stress, fatigue and poor work ife baance, can generate organisationa and domestic difficuties, may not be sustainabe and may be especiay probematic for those in hybrid manageria roes in which rapid and intense context switching between different kinds of compex tasks coud increase human error. Given the mutipe roes of midde managers in keeping the show on the road, mediating between the front ine and top team and driving change and innovation, it may be usefu to consider strategies for reeasing time to manage in the face of increasing workoads and decreasing resources. Queen's Printer and Controer of HMSO 2013. 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. 41

THE REALITIES OF MIDDLE MANAGEMENT One research priority arising from this anaysis concerns the deveopment of a better theoretica and practica understanding of the concept of management capacity, and of how capacity can be assessed and strengthened in a context of financia constraints. A second research priority concerns understanding the nature, incidence and impications of extreme jobs among heath-care managers, aong with ways to redesign such roes, and/or provide better forms of support for those who hod extreme jobs, incuding resiience training. Studying management roes in the 1980s, Scase and Goffee 116 described a context in which (conservative) government poicies were increasing pressure on a organisations to be more cost-effective and efficient, with corporate restructuring reducing management job security. Expectations of persona deveopment and opportunities to exercise independent judgement were not being met, and midde managers were being asked to achieve goas with imited resources, and with tighter monitoring of standards. Scase and Goffee 116 reported that the reuctant managers in their study were abe to adapt by investing very itte of themseves in their work and merey performing their jobs to an acceptabe minimum standard, particuary in bureaucratic settings with more rues and constraints, and with more scope for minimaist roe paying (p. 51). These observations concerning cost pressures, insecurity, reguation and diminishing resources appy to heath care in the second decade of the 21st century. However, rather than respond by decreasing persona investment in work, for many heath-care midde managers in the current study the issue concerned potentiay excessive persona investment, in the form of extreme jobs. The management roe Interest in management work dates from 1956 and Whyte's The Organization Man, 117 which created the stereotype of the compiant, risk-averse bureaucrat, an image that survives into the 21st century in characters such as David Brent, the manager in the teevision comedy series The Office. Whyte's account was foowed by numerous other studies of management roes. From observation in a chemica pant in the American Midwest, Daton 118 noted that departures from forma organisation processes were required to make the pant run smoothy, emphasising the roe of informa networks, office poitics and persona infuence. Foowing in Daton's ethnographic footsteps, Watson 6 documents the rewarding and painfu reaities of managing from his study of a teecommunications factory in the British Midands. The subtite of Watson's book is cuture, chaos and contro, highighting dimensions of the management work that he observed. Mintzberg 4,119,120 describes the activities of management on the panes of information (communicating, controing), peope (eading, inking) and action (doing, deaing). He aso describes the pace, brevity, variety, fragmentation and discontinuity of management work, and the preference for action and informa and ora communication. Defining management as deciding what shoud be done then getting other peope to do it (p. 6), Stewart 5 is aso concerned with management activities panning, organising, motivating, controing, co-ordinating, staff deveopment noting the variation in management roes, and the fragmented, chaotic and hectic nature of the work. From his study of genera managers, Kotter 7 notes the ong working hours (60 90 a week) and the considerabe time spent in conversation, asking questions, joking and persuading but this is inteigence gathering, not time-wasting. Haes 22 portrays the variety in management work, which typicay invoves activities such as acting as figurehead, monitoring and disseminating information, networking, negotiating, scheduing and monitoring work, aocating resources, human resource management, probem-soving, innovating, and technica tasks reating to professiona or functiona speciaisms. Management thus invoves an inescapabe preoccupation with routine... keeping the show on the road (p. 51), reacting to events, focusing on the urgent and unforeseen, accompanied by tension, pressure and confict in jugging competing demands. There is aso considerabe choice and negotiation over the nature and boundaries of the management job and how it is done. 42 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Haes 22 notes that the focus on what managers do overooks the impact of those activities. The management contribution is expored in the foowing chapter. However, it is important to note that evidence concerning midde management contributions to organisationa effectiveness departs from the stereotype of bureaucratic bockers. It is now recognised that midde managers pay a key intermediating roe between front-ine operations and senior management. 30,121 Midde managers have aso been identified as key change agents, 122 eading change quiety 14,123 and beow the radar, 124,125 as ideas practitioners, 126 as we as impementing, synthesising, championing and faciitating strategic organisationa change. 12,29 How are midde management roes themseves changing? From their study of eight pubic and private sector organisations in six Western European countries, Dopson and Stewart 127 chaenged the image of midde managers as frustrated, poweress and disiusioned with dreary jobs in rigid hierarchies. They found midde managers responding to compex and changing pressures, with increased workoads and responsibiity, with accountabiity for a wider range of duties, seen by senior management as pivota to impementing change. Midde managers had to become more fexibe and generaist, and shorter hierarchies had put them coser to the top team. Hassard et a. 128 interviewed 250 managers in 30 organisations in the USA, the UK and Japan, concuding that midde management roes have become more chaenging, with onger working hours, increased performance pressures, expectations of rapid resuts and a burring of work domestic boundaries. This may be offset by higher saaries, greater responsibiities and more interesting work, but the overa feeing of being overwhemed in work whie the traditiona promotiona adder has been argey removed was a major and widespread finding (p. 228). However, this study aso found that midde managers were highy motivated despite the pressures, and they argue that performance coud be improved if the pressures were reeased. In addition, authoritarianism and top-down rue were aive and we (p. 13); there was not much sign of the post-bureaucratic organisation. The evidence thus shows that midde managers have an increasingy varied range of responsibiities, with ong working hours and rising performance expectations, paying key roes in operationa and human resource management, mediating between the front ine and top team, contributing to strategy, innovation and change. These features aso appy to midde management work in heath care, as expained beow. Midde management in heath care Over the past decade, ayers of nationa and regiona organisations have accumuated, resuting in excessive bureaucracy, inefficiency and dupication. The Government wi therefore impose the argest reduction in administrative costs in NHS history. Over the next four years we wi reduce the NHS's management costs by more than 45%. p. 43 1 Despite evidence confirming the significance of midde management, the stereotype of the petty bureaucrat prevais in heath care, where management costs are associated with wastefu bureaucracy. Hyde et a. 129 argue that denigration of the function obscures vita strategic and co-ordinating work, that midde management is an identity that nobody wants and that midde managers have become a ost heath service tribe. However, Currie and Procter 51 stress the importance of the dipomat roe of midde managers in a professiona bureaucracy, mediating between medica and corporate goas. Carney 130 and Pappas et a. 131 argue that the strategic midde manager has become more, not ess important in heath care. Nationa poicy has rejected those perspectives. Hyde et a. 129 observe that itte is known about the reaities of heath management and midde management work in the NHS is obscured (p. 18). One reason for the ack of evidence perhaps concerns the distributed nature of the function, which does not comprise a we-defined group; 132 iterature reviews must rey on search terms such as ead nurse, ward sister, modern matron, service ead, cinica director Queen's Printer and Controer of HMSO 2013. 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. 43

THE REALITIES OF MIDDLE MANAGEMENT (see Chapter 2). A second pausibe reason reates to the stigma attached to midde management, making this group difficut to identify. In addition, a search for reevant iterature reveas more commentary than research, which is more ikey to be pubished in sector- and occupation-specific journas than in genera organisation and management studies journas. The current study thus seeks to contribute to our understanding of those management reaities. A review of pubished evidence eads to eight observations. First, research focuses on nurse management roes and cinica directors, with ess attention to other midde manageria eves and non-cinica management roes. Second, hybridisation has meant changing job tites, from ward sister to ward manager (in the UK 133 ), from charge nurse to nurse unit manager (in New Zeaand 134 ), refecting expanding roes, covering arger areas and more staff, and increasing workoads with onger working hours. 135 138 Third, hybridisation invoves cinica staff in budgeting, human resource management, panning, change and administration. 139 144 Fourth, midde managers (pure pays and hybrids) have been subjected to increased monitoring and accountabiity. 145 147 Fifth, the significance of the bridging roe of midde management, between front ine and top team, has increased. 148 Sixth, these changes have taken pace in the absence of adequate preparation for those moving from cinica to hybrid roes. 149 Seventh, hybrid midde managers have probems baancing cinica and organisationa priorities and resource aocations. 150,151 Finay, the emphasis in midde management roes has shifted towards change agency and eadership. 152 154 Research aso suggests that midde managers face severa probems in addition to workoad and competing stakehoders. They are often excuded from decision-making and fee isoated and controed. 141,155,156 They have difficuty infuencing and chaenging doctors 51,157 and work with ambiguous ines of responsibiity. 158 Hybrids report tensions between cinica and operationa priorities, 159,160 aong with difficuty baancing professiona deveopment with work objectives, 161 and the transition from a cinica to a hybrid manageria roe raises identity issues. 156,162 Hybrids are aso concerned about isoation from their professiona peers. 157 Many fee that they ack support and are unprepared for handing human resource management issues. 163 They are aso acutey aware of the negative stereotype devauing management and threatening job security. 1,145,152,164 In sum, midde managers in heath care face a range of pressures simiar to those in other sectors, incuding widening roes, increasing responsibiity, onger working hours, work intensification and more intrusive performance management. However, the management popuation of the NHS comprises a heterogeneous combination of pure pays and hybrids, who aso have to contend with the chaenges of driving change in a professiona bureaucracy, a negative stereotype and, for hybrids in particuar, a perceived ack of preparation for, and subsequent support in, manageria roes. Management survey findings This section summarises findings from our survey, conducted in 2011. Using 5-point Likert-scaed items, the survey had five sections: reaities, job characteristics, organisationa outcomes, job satisfaction and persona experience. Items aso incuded a widey adopted organisationa commitment scae 165 and a simiary we-recognised set of stress indicators. 166 The survey was distributed by e-mai at five trusts, covering staff with manageria and hybrid roes. The response rate varied from 77% at Greenhi (distribution was confined to the trust's 100 eaders ), to 19% at Cearview and Netherby. The overa response rate was 24%, generating 611 usabe responses. Of those, 18% had management roes and 51% had hybrid roes; 31% did not answer this question. Of the tota, 42% were femae and 19% were mae; 39% did not answer this question. Over two-thirds of responses fe into five categories of work: management, administrative and cerica, project management, nursing and finance. Further detais of the survey administration, aong with sampe properties, response rates, frequency distributions for the whoe sampe and responses for each trust, are reported in Appendix 3. 44 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Some findings were anticipated, others were surprising and some are cause for concern (percentages cited here are the aggregates of either agree and strongy agree or disagree and strongy disagree ; Appendix 3 reports the detaied breakdown of responses across the fu scae). Anticipated: motivation, commitment, change orientation, uncear responsibiities Interviews and focus groups reveaed midde managers to be highy motivated and deepy committed and survey responses confirmed this: 75% indicated that they were motivated by making a difference to patient we-being, 90% were motivated by deveoping others and 94% fet that their work made an organisationa contribution. The shift in the focus of management work towards change was aso confirmed: 65% said that they exercised infuence in their areas, 70% got a buzz from the chaenge in the job and amost 80% agreed that they had become more businessike in their approach to managing. A of the trusts in this study had recenty undergone, or were about to experience, interna reorganisations in addition to changes to nationa governance, reguatory and commissioning structures. Thus, athough 70% agreed that they were cear about their own roes, 56% said that it was often uncear who was responsibe for what. Surprising: absent stereotyping, extreme jobs, ow satisfaction There was itte sign of the negative management stereotype or of the traditiona animosity between cinica and manageria professions: 60% said that cinica staff vaued their management contribution, 70% did not resent reducing cinica duties to carry out management work and 76% were happy to be seen as a manager. This was surprising as some interviewees had denied having manageria responsibiities (athough in the judgement of the interviewer they ceary did); one operations manager expained that he never described himsef as a heath-care manager at socia events, another described the favourite catchphrase of a senior consutant with whom he worked cosey as those wretched managers and one trust asked that the project subtite, which appeared on participant information, be changed from midde and front-ine management work to a study of manageria and cinica eads. Happy to be a manager was broady consistent across a five trusts. Interviews and focus groups suggested that some midde managers had extreme jobs, with fast pace, intense effort and ong hours. 167 A heath-care variant on the origina mode was thus deveoped. Responses to those survey items suggest that this phenomenon is more widespread than anticipated. The impications are discussed in Extreme jobs, resiience and job crafting. Aso surprising was the ow proportion 28% indicating satisfaction with their organisation, with ony 50% expressing satisfaction with their job. Commitment to patients, coeagues and the work ceary does not transate into satisfaction with the job or the organisation. Cause for concern: workoads, safety, persona costs, disaffection The managers responding to this survey appear to have been pressured by heavy workoads and to have had inadequate resources: ony 30% thought that resources were sufficient for their roe, 58% said that their roe was unmanageabe, 68% said that they did not have enough time for their management duties, 80% said that pressure to meet targets had risen and 90% said that the focus on cost-effectiveness had increased. A second cause for concern reates to the possibiity that patient safety is compromised by financia pressures: 51% agreed that trade-offs were made between safety, quaity and finance, and 54% agreed that financia pressures put patients at risk (22% strongy). A third source of concern reates to the high persona costs of the pressures in management roes, with ony 30% indicating that they coud maintain a satisfactory work ife baance and 50% worrying about probems, having difficuty unwinding and feeing used up and exhausted after work. Queen's Printer and Controer of HMSO 2013. 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. 45

THE REALITIES OF MIDDLE MANAGEMENT Finay, three items indicate a degree of disiusionment: 26% said that an offer of more money woud tempt them to eave, 42% said that they sometimes fet ike eaving for good and 44% fet that they had reevant capabiities that were not being used in their roe. These resuts are broady consistent with the findings from the study of trends in midde management work by Hassard et a. 128 discussed earier, and have potentiay significant impications. First, at an individua eve, those kinds of pressures are not sustainabe and can be expected to affect stress, burnout, performance and the abiity to retain capabe staff. Second, this context is hardy conducive to the commercia, entrepreneuria, innovative approach to service redesign and deivery improvement that heath-care managers in the acute sector have been encouraged to adopt. Finay, and perhaps most seriousy, is the observation that patient safety is being compromised. Patient safety was a nationa priority during the ife of this project, but nationa poicies appear to have been contributing to creating an environment in which that priority was undermined. Motives and rewards The stereotype suggests that midde managers are motivated by bureaucratic rues, organisationa stabiity and administrative order. The reaity is different. Survey responses suggest that midde managers have other motives and information from set-up interviews supports this observation. Here, findings from two trusts eaborate this point, and evidence from others is briefy presented. Netherby At Netherby, 17 set-up interviews were conducted with four board members, seven hybrids and six managers. In response to the question, what in your opinion are the motives and rewards for midde managers in this trust?, interviewees generated 40 responses; content anaysis suggested the six main themes (and an other category) summarised in Tabe 19. Anaysis of answers to this question from 12 interviewees at Greenhi (two board members, four hybrids, six managers) is shown in Tabe 20. This group identified 42 items divided into nine themes. The anaysis reveas a combination of professiona (making a difference), intrinsic (feeing vaued) and ideoogica (pubic sector commitment) motivations. However, one-quarter of items for both trusts concerned pay, conditions and job security. In the financia cimate prevaiing during this project, the roe of hygiene factors is not surprising. This pattern was echoed across a six trusts. For exampe, nine interviewees at Burnside identified improving patient care, recognition, doing a good job, persona and career deveopment and the hospita's convenient ocation. Seven interviewees at Cearview identified making a difference, overcoming chaenges, improving patient care and safety, persona accompishment and working with exceptiona and inspirationa peope. Motives from a mixed focus group at South Netey incuded making a difference, improving the patient experience, seeing the impact, being inspired and energised by coeagues, progression, ean efficient work, persona fexibiity, seeing others enjoying their work and taking pride in the job, recognition, and sharing ideas and practice. A genera manager at South Netey added, The inteectua chaenge of deaing with wicked probems. You get a tremendous kick when you pu it off, and Massive peer support, working together, common goas. Despite mentions of hygiene factors, comments such as It's not about money were aso common. However, the other and strugging to answer themes at Netherby and Greenhi, respectivey, confirm the disaffection reveaed in survey responses: There are no rewards for midde managers. Deputy director, Netherby 46 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 19 Motives and rewards for midde managers at Netherby Theme Item count Iustrative comments Making a difference 13 Make things better for patients ; see improvement, give it a go Buzz from innovation ; take risks, think beyond the current setting Motivating to earn from incidents and impement changes Setting up projects to improve things can be highy motivationa We want to be performing better, encouraging improvement Doing a good job 9 Managers get a buzz from things coming together Job satisfaction, see things through ; hep deiver high quaity care If the organisation is successfu, that is satisfying Motivated by deivering care that compares with what our peers are doing Hygiene factors 9 Good empoyer ; pensions, terms and conditions, good retention Career routes, aways somewhere to go Reward package, hoidays and sickness benefits good Security, important in this sector, now chaenged Feeing vaued 4 Feeing vaued ; done a good job, somebody just saying we done Feedback from patients and coeagues is satisfying Persona deveopment 2 Keeping up to date with the atest deveopments Buid up speciaist knowedge and expertise Pubic sector vaues 1 Pubic service, you don't join to make money as a midde manager Other 2 At the exec eve, the motivations are to see the hospita improve and taking the hospita forward; midde managers motivation is not making mistakes and keeping within budgets' (board member) The experience of midde managers is, they ony get beaten up. It is rare for midde managers to participate in an interesting improvement project. There are just not so many opportunities to take risks and introduce innovations in the current cimate. Medica director, Netherby There are few or no rewards, either financia or in terms of appreciation. Cinica director, Greenhi We're bad at recognition, and peope say, we don't fee vaued. We don't make best use of non-pay benefits. Associate director, Greenhi I have to admit that I strugge sometimes to remain motivated. I'm not aways enthused from above. I've been working today with a junior nurse, and we had the patients singing; it was great. I work on a short stay acute medica ward. We need to keep asking, what do our patients want, what do they expect that motivates me, and I ove my job. But being summoned by management, being chaenged constanty, that's not motivating. Ward sister, Netherby Queen's Printer and Controer of HMSO 2013. 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. 47

THE REALITIES OF MIDDLE MANAGEMENT TABLE 20 Motives and rewards for midde managers at Greenhi Theme Item count Iustrative comments Making a difference 8 It's rewarding for managers who can try out new ideas We are trying to change, there's a ot of innovative work going on Rewarding to work on a concern, to make a difference to patients The opportunity to deveop the service as a whoe is exciting Hygiene factors 7 The pay is good ; we treat peope we ; so far jobs are safe Leave and sick pay and pensions are generous Lots of deveopment opportunities Doing a good job 5 On the front ine, when they get it right, that's very rewarding The vast majority of patients are happy with the services we provide Our rewards strategy reies on professionaism and integrity Feeing vaued 3 Most peope respond to having their work acknowedged The itte thank you's, which aren't often, a etter saying we done Coeagues 3 I work with an amazing team; peope who ove their jobs, good humour Everybody vaues other professions ; peope take pride in their division Pubic sector vaues 3 A ot of NHS managers beieve in the NHS I care passionatey Deveoping others 3 Seeing peope turn themseves around and become more supportive Rewarding to hear someone say, I think I coud chair that meeting now Inside track 2 My position gives me inside knowedge, strategic understanding Voyeuristic, working with different groups, goba view of the service Strugging to answer 8 I'm strugging to think of motivation and rewards This is a tough pace to work at the moment; managers are having to fight through difficuties and fix them, and this is an ongoing strugge Do you get through the first few years, or get destroyed in the first year? The motivations and rewards for midde managers thus incude making a difference, driving innovation and change, doing a good job, feeing vaued, deveoping others, working in high-performing teams and persona deveopment. There was aso a view that rewards were acking, that contributions were not being recognised and that senior eadership styes were demotivating. Athough this was a minority position, 42% of survey respondents agreed or strongy agreed with the item, I sometimes fee ike eaving this empoyment for good. At three trusts, Greenhi, Netherby and South Netey, that proportion was around 50%. How is the roe changing? I manage the PALS [Patient Advice and Liaison Service] team of three officers across the two sites, four compaints officers, and staff in patient and pubic invovement who I have aso picked up. I have just got them organised and they are working we. My aim is to vaue and nurture my staff and I've put a ot of emotiona investment into deveoping the team. Now I have to find 27,000 savings over two years; 48 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 12,000 ast year, which I didn't achieve, and 15,000 this year. Starting from January 2010. I have just got them organised, and now this. I want to weep. Senior manager, Greenhi Midde managers in genera have seen their jobs enarged, their responsibiities widened, the pace and intensity of work increased, working hours engthened and performance monitored more cosey. Midde managers in heath care face broady simiar issues. From survey data, Tabe 21 shows the proportions who agreed/agreed strongy with 14 items that sought to capture these trends. For the first four items, around 80% or more agreed, refecting pressures stemming from the government poicies being pursued during this project, concerning cost-effectiveness, targets, commercia orientation and performance monitoring and reguation. Responses to the next four items capture the consequences for individua management roes: ack of time, insufficient resources, unmanageabe workoad and unsatisfactory work ife baance. Ony one-third or ess did not rate those issues as probems. Items 9 and 10 concern the human resource management impications, passing pressure down the organisation, and finding it more difficut to motivate staff respectivey. The ast four items appy to hybrid roes, with cinica staff increasingy taking on manageria roes. However, athough just over haf of respondents agreed that they had probems baancing manageria and cinica responsibiities and >40% said that they had reduced cinica duties accordingy, given the pressures on a midde managers it might have been anticipated that the proportion of hybrids experiencing this cash of priorities woud have been much higher. Aso surprising is the ow proportion ess than one-third expressing resentment at having to reduce cinica responsibiities in favour of manageria work. This again contradicts the negative stereotype of heath-care management and is aso at odds with the image of heath-care professionas who are supposed to pace a ow vaue on the management roe. This suggests that the traditiona tension between white coats and grey suits may be eroding, with recognition of the need for coser interprofessiona coaboration in the face of the range of compex chaenges facing the sector. TABLE 21 How is the midde management roe changing? Item % agree 1. The need for me to focus on cost-effectiveness has increased 88 2. The pressure for my department to meet targets has increased 83 3. The need for me to be more businessike and commercia has increased 78 4. The amount of bureaucracy that I need to dea with has increased 78 5. I have enough time to compete a of my management duties 21 6. I have sufficient resources to carry out my management responsibiities effectivey 30 7. My overa workoad is usuay manageabe 31 8. I am abe to maintain a satisfactory work ife baance 34 9. As the pressure on me increases, I have to pass the pressure on to the staff for whom I am responsibe 51 10. It is becoming harder to motivate staff in the current cost-cutting cimate 71 11. The expectation that cinica staff wi take on manageria roes has increased 71 12. I often strugge to baance the priorities of both my manageria and my cinica roes 53 13. I have had to reduce my cinica work to fufi my management duties 44 14. I resent having to reduce cinica responsibiities to undertake manageria work 29 Queen's Printer and Controer of HMSO 2013. 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. 49

THE REALITIES OF MIDDLE MANAGEMENT Detais behind those responses can be seen in the focus group discussion with three ead nurses at Greenhi. Their insights, summarised in Tabe 22, refect dimensions of the management agenda discussed earier and were typica of responses from other groups about changes in management roes. This is a beak picture, suggesting that managers ack the time, resources and support to fufi their responsibiities effectivey. The threats and bame, bureaucracy, inspections, tension, firefighting, increasing workoads and ack of trust and autonomy are ikey to work against pressures to be more adaptive, creative, innovative and commerciay orientated. Nevertheess, focus group participants invariaby expressed their commitment to the service, to their profession and to patients. The beak picture must be set in the context of positive responses under other headings, particuary with regard to motives and contributions. One concusion is that, if the trends captured in Tabe 22 were to be reversed, the resutant effect on motivation, commitment and contribution coud enhance individua, divisiona and corporate effectiveness consideraby. This set of issues is discussed in Chapter 6, in terms of buiding and sustaining an enabing environment for management work, in which most of the appropriate actions are cost neutra, requiring changes in attitudes, behaviours and processes. These changes appear to have taken some management roes in a different direction, creating for some what have been described as extreme jobs, which are the subject of the foowing section. Extreme jobs, resiience and job crafting Are the dimensions of the changing roes of heath-care managers undesirabe? This section offers a more nuanced response, based on the concept of the extreme job, identified by Hewett and Luce 167 among high-earning professionas in aw, finance and consutancy. They identified 10 dimensions of such roes, but four appear to be ess reevant in heath care: direct reports, entertaining cients out of hours, profit and oss responsibiity and internationa trave. From the preceding discussion of how management roes are changing, the other six dimensions that may appy are: TABLE 22 How management roes are changing a ead nurse perspective There's more... There's ess... Uncertainty: it's not cear, to which master do I answer? ; new structure, uncear management roes Patients: under pressure from growing patient numbers ; no evidence of care moving into the community Tension: between us and managers who're paid more ; arguments over finance rues and aowances Threats and bame: weeky performance management threats ; when things go wrong, it comes back to me Bureaucracy: our hands are tied with micromanagement ; red tape; ayers and ayers of poicies Inspections: overapping and contradictory ; information, reports, action pans Loading responsibiity onto me: get this done ; the nurses wi do it ; what do you want me to stop doing? Panic, knee-jerk, firefighting: we're aways firefighting, kneejerk responses ; what are we going to panic about this week? Trust: we're not trusted to manage ; we're not aowed to use our experience Autonomy: it's not your own workoad any more ; everybody has a say in running my business Money: there's no money to improve things ; can't backfi to support training Support: support services don't do either ; imited administrative support Management deveopment: division head has no management training ; you get put in post then given training Time: we're pate-spinning a the time ; there's no such thing as out of hours here And there's aso more... E-mais: e-mais copied to everyone by peope who need to cover their backs; it's dog eat dog 50 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 1. unpredictabe work patterns 2. fast pace with tight deadines 3. broad scope of responsibiity 4. 24/7 avaiabiity 5. mentoring and coaching other staff 6. ong working hours. Our focus group evidence suggested a further six extreme heath-care dimensions, which are iustrated here with candid quotes from participants (the sources of the foowing quotes are omitted to preserve anonymity): 7. Making ife or death decisions: We were on the unit whie the aarms were going off, and the patient kept going into cardiac arrest. It was disturbing from my perspective, because I'm a nurse by background and I've worked in ITU [Intensive Therapy Unit], and they were fying around, the arrest button was going, aarms were going and it was very hard. 8. Deaing with conficting and changing priorities: It's a case of, what are we going to panic about this week? We have more to dea with. There are so many competing priorities and edicts, it's easy to get swamped and forget why you're here. There wi be a big push on something, because we're having a visit, or we're non-compiant in an area, so we do that, then forget it, and move on. We're having a visit about safeguarding, so that's in vogue. 9. Doing more with fewer resources: I was tod to get that racking off the foor, by screwing it to the wa. But I can't do that; it costs too much. I can't spend 400 on a bit of equipment, an ophthamoscope, but we coud be sued if a symptom is missed. Medica engineering want 35 a year for the maintenance contract. So, no new equipment. We're facing greater demands. It's hamsters on the whee. We need head space. It's ike Winnie-the-Pooh being dragged backwards down the stairs by Christopher Robin; there must be a better way to come downstairs, if ony I coud stop bumping and think about it. 10. Responding to audit, compiance, reguation and inspection agencies: Responding to reguatory bodies, a coming at it from different anges. I spent ast week just fiing in forms, responding to request for information. I had no time to do anything that woud make a difference. I've been inspected by the SHA, OFSTED, LINKS, CQC, HOSC, HSE. They have different requirements, which overap, but they have different parameters. They a want information, reports, and action pans, which contradict each other. 11. Big tent probem-soving ; the need to get many peope to agree: I think I'm creative at finding innovative soutions. But impementing anything new takes massive amounts of energy, and you are ground down. You get doors cosed in your face repeatedy. There's so much red tape. Our hands are tied. I have to get four sign-offs before I can recruit a nurse. We're not trusted to manage. 12. The foggings wi stop when morae improves: There are no meetings where you are given credit for success. It doesn't matter what we do, it's never good enough. Queen's Printer and Controer of HMSO 2013. 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. 51

THE REALITIES OF MIDDLE MANAGEMENT My genera manager is ike the grim reaper. No positives, a negatives. We never get any thanks or positives, even when we have made our targets. This 12-component profie was used to design a simpe diagnostic with items such as, I never know what's going to happen next in this job (unpredictabe work patterns), I'm aways trying to meet another deadine (fast pace, tight deadines) and so on. This was competed by six members of an operations management team at Cearview, who were asked to respond yes or no to each item on the premise that yes to six or more items impied an extreme job. The group commented: I answered a but one of the questions with a yes. I have tried to stick to my working hours (minus unch) and have just seen the work pie up. Directorate support manager I can answer yes to a the questions. Some parts I ove, but there are many days where I woud ike space to think. This is becoming more precious. We have made errors through firefighting, but we appaud ourseves when we go phew that was a ucky escape. Operations manager Answers are a mix of yes, no, and sometimes. Operations manager This is reasonaby baanced, not exaggerated or understated. The greatest frustration in medica management is the chaenge of producing change in an environment that is very resistant. Consutant The adrenain rush can occur without the need to rush around. Great coeagues are even greater if you don't get so tired that you snap at them. Discharge panning manager There is a great dea to be said for peope who manage their workoad in a way that means that they work their hours (pus some extra when necessary). They shoudn't fee bad about working their contracted hours. Deputy operations manager This piot suggested that the concept of an extreme job profie for heath-care management had face vaidity, judging by the first four responses, and that jobs vary in substance and over time on those dimensions. Some fee that extreme jobs shoud not be necessary. This diagnostic became the job characteristics section of the survey. Responses to the 12 items are shown in Tabe 23. With one exception, agreement with the items was high, ranging from 54% (reating to unpredictabiity) to >90% (doing more with ess). This response pattern suggests that the incidence of extreme jobs (as defined by these items) in heath-care management is widespread. Ony around 30% agreed with the ast item, a resut inconsistent with focus group comments. Either those comments were misinterpreted, or this item was bady worded; an item reading it is never good enough for senior management may have produced different resuts. As expected, those with high extreme jobs scores aso indicated higher stress eves and poorer work ife baance. Interestingy, the positive reationship between having an extreme job and being under stress was stronger in men, despite the fact that women were more stressed generay. There was no reationship between extreme jobs and commitment, the atter being more cosey associated with infuence, recognition and buzz. 52 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 23 Is your management job extreme? Item % agree I never know what's going to happen next in this job 54 I'm aways trying to meet another deadine 81 My management responsibiities just seem to keep expanding 68 I am constanty expected to respond instanty 77 I am responsibe for showing ess experienced staff how to perform effectivey 78 I frequenty arrive earier and/or eave ater than my contract requires 83 I make decisions that directy affect the ives of patients 76 My priorities change every week 58 I am expected to improve the service we provide despite resources being cut 93 A ot of my time is spent responding to requests for information, reports and action pans 76 I have to get arge numbers of peope to agree even to make sma changes 66 It doesn't matter what I do, it is never good enough 32 Hewett and Luce 167 found that extreme jobbers were attracted by the chaenge, enjoyed the work and fet fufied by it. Asked, why do you do it?, they mentioned adrenaine rush, great coeagues, good pay, power and status and recognition for achievement. Those items were added to our survey design and responses are summarised in Tabe 24. We know that heath-care managers are motivated by the chaenge and the buzz that make extreme jobs attractive. We aso know that working with coeagues in high-performing teams is another key motivator. However, ess than haf thought that they were we paid, and recognition, power and status appear not to be experienced by around two-thirds of this sampe. Other evidence shows that heath-care managers are aso motivated by making a difference, driving change and innovation, doing a good job and deveoping others. The heath-care variant of the extreme job profie proposed here may thus be accompanied by a heath care-specific motivationa profie reying at east in part on professiona and pubic sector vaues and purpose, which may offset or buffer or compensate for the negative aspects of extreme jobs. The subtite of the artice by Hewett and Luce is the dangerous aure of the 70-hour workweek. High-performing adrenaine junkies, in particuar, appear to enjoy this kind of work, 168 so where is the danger? Mutitasking for ong hours across compex roes can ead to fatigue, burnout and mistakes. 169 TABLE 24 What are the rewards from your extreme job? Item % agree I get a buzz from the stimuation and chaenge in my job 71 In my job I get to work with high-caibre coeagues 68 I am we paid for what I do 48 I get recognition for my achievements in this job 40 I enjoy the power and status that I have in my roe 36 Queen's Printer and Controer of HMSO 2013. 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. 53

THE REALITIES OF MIDDLE MANAGEMENT In such circumstances, famiy ife may aso be adversey affected. In a heath-care context, patient safety and care quaity coud potentiay be compromised. In addition, working constanty at this pace may not be sustainabe. 170 Ony one-third of survey respondents said that they were abe to maintain a satisfactory work ife baance. But an improved work ife baance coud create a cimate that is not chaenging enough for the A payers, who then become more difficut to recruit and retain. A varied, intense, fast-paced roe with responsibiity and ong hours can be rewarding. The fact that such jobs can be attractive, however, coud be a probem. The origina research found extreme jobs among high-earning professionas. This study suggests that some midde and senior managers in acute heath care may aso have jobs that are extreme, in terms of the profie suggested here. Most hospita managers are hybrids, covering manageria and cinica responsibiities. If the management component of their roes has become more extreme, this may affect the time and energy that they devote to patients, coud increase the potentia for errors and may aso discourage cinica staff from taking on such jobs in the first pace. In addition, some of the extreme heath-care job dimensions are potentiay demotivating: competing priorities, having to do more with ess, the burden of reguation, bureaucratic barriers, a cimate of negativity. The assumption that a extreme jobs are exhiarating and motivating is miseading; some are exhausting and frustrating. There are substantia research traditions with regard to heavy work investment topics such as ong hours, work intensification and workahoism. However, research into extreme jobs has been imited, perhaps because of the non-academic source of this concept. A iterature search identified ony two other studies, 171,172 which found that onger hours were associated with higher satisfaction, better career prospects and higher saary, but with higher eves of stress, more psychosomatic symptoms, ower famiy satisfaction and poorer emotiona heath. Deveoping resiience This suggests that surviva in an extreme job requires a degree of menta toughness and persona resiience, in addition to an abiity to manage stress. Discussing senior executive roes in the NHS, Sergeant 173 observes that, athough there are numerous eadership deveopment programmes avaiabe, it is much more difficut to teach the poitica skis, attitude, resiience and the robustness required to survive in a high pressure environment (p. 13). Defining individua resiience in terms of rebounding despite adversity or change (p. 3), Lewis et a. 174 review research in this area, and expore a range of strategies, toos and resources for deveoping individua, team and organisationa resiience. The US Army, with around 1.1 miion members, and thus simiar in size to the NHS, has deveoped a Comprehensive Sodier Fitness (CSF) programme, the aim of which is to increase psychoogica strength and positive performance and to reduce the incidence of maadaptive responses (p. 4). 175 The subtite of this reference is buiding resiience in a chaenging institutiona context, and the potentia reevance of this approach in heath-care settings shoud thus not be dismissed. Another aim of the CSF is to insti post-traumatic growth, with universa resiience training. The experience of adversity is thus a potentia source of meaning and persona growth, and post-traumatic stress does not become a probem. The authors of this programme suggest that, athough reevant to US Army members, resiience training may be reevant to other arge institutions. The design of work is not static. Individua-eve aternatives to extreme jobs may be found in job crafting, which invoves proactive adjustments to activities, time and work intensity, 176 and in i-deas, 177 in which individuas negotiate their own idiosyncratic terms with an empoyer. Work can aso be redesigned at a group eve, to caibrate the efforts of those who wish to imit their hours in an extreme jobs cuture. 178 This study did not aim to expore the nature and consequences of either job crafting or i-deas. However, aspects of both of these perspectives were apparent in the information provided by some respondents, and are discussed here briefy for the purposes of iustration. Given the potentia impact of extreme jobs on individua and organisationa effectiveness, and on quaity and safety of patient care, this is an area where further research woud be vauabe. 54 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 To iustrate the nature of job crafting, Tabe 25 summarises the dimensions of the roe of one modern matron in one of the trusts participating in this study (trust not named to preserve anonymity). In practice, these dimensions are cosey inter-reated and are separated here for anaytica purposes. This profie is based on an extended interview during which this matron described how the roe refected her professiona training and persona preferences, as we as the forma job description. This is a senior nurse hybrid roe, which in this case incuded five areas of cinica responsibiity and 20 eadership, organisationa and manageria areas, indicating where the emphasis of this roe ay. This is someone who is deepy committed to nursing and to the roe of modern matron, who enjoys her work thoroughy and who is enthusiastic about sharing her views and experiences with others. Describing her approach to her roe, she said: How often do I work a thirty-seven and a haf-hour week? Never. I've got a good directorate manager who in the end kicks me out. But I normay work from seven ti five or six, most days. And I don't have to work that. It's just, I fee, if I'm not in eary I don't see my night staff, and I ike to be there for them. And I need to know that each of my shifts is OK, is fine. So my time management coud be better. TABLE 25 A modern matron's roe dimensions Cinica roes Nursing: work cinicay twice a week, check patient needs and moods Cinica probem-soving: probem patients, fas, concerns Customer reations: working with and reassuring reatives Liaison: with PALS, acting on issues where appropriate Change agent service improvement: infection contro, patient experience Leadership roes Head nurse cover: head nurse is monitor, controer, co-ordinator Leader: on the shop foor, iving, breathing, hands-on but detached Change agent process innovation: ward efficiency, ean, deveoping ideas Roe mode: for ess experienced nurses Enforcer: dress code, infection contro reguations Organisationa roes Linking pin: shop foor to top team, share good practice Team payer: work with ward sisters partners not disempowered Fixer: expore nursing issues and provide support and resources Compaints hander: resove issues from patients, reatives, doctors Management roes Operations manager: oversee three wards (100 beds), monitor patient fow Performance manager: weeky reviews and budget meetings Safety manager: safe ward staffing, infection contro Quaity manager: saving ives audit too, achieve quaity standards Training and deveopment manager: deveop staff, customer care for nurses Support roes Supervisor: giving voice to heath-care assistants Morae officer: enthusing, motivating, vauing, praising staff Thermometer: wak the foor at 0700, speak to a patients and staff Supportive ear: matron's cinic twice weeky anyone can raise anything Coach and mentor: for junior nurses Human shied: buffer against senior management criticisms Queen's Printer and Controer of HMSO 2013. 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. 55

THE REALITIES OF MIDDLE MANAGEMENT OK, I'm a feey person. And you have to fee it. If you don't fee it, we don't want you in this directorate. If you don't fee that pain, if you don't fee that upset and I'm reay passionate I wak on my wards and I want... boom, boom, boom... and they understand that, and at seven in the morning, bess them, they are saying, C, we don't need your boom, boom, boom. But I do; I want boom, boom, boom... it's a bue sky out there. And I know that everybody's not ike that. And I don't expect it of other peope. But I aso don't want someone to... which some of the new nurses fee... that we shoud fee gratefu that they are here, that they are on a five-day stretch and they haven't had a day off yet, yeah, and chopped iver. Nurses get paid a good saary now. We're a bit ike farmers; we' aways cry poverty. But if we're paying good saaries we need something back. We need them to have a bit of ownership, accountabiity, responsibiity. Given the hours, the scope of responsibiity and the mutitasking, this can be described as an extreme job. However, those properties of the roe have either been chosen or emphasised by this individua. Not everyone hoding a modern matron position wi wish to carry out to craft this roe in this manner. To expore those variations, a senior cinica nurse (modern matron) at one of the other five trusts participating in this project was asked to compare this profie with her own roe. For the purposes of this discussion, her response had two main components. First, this profie was recognisabe, being broady simiar to her own roe. Second, she observed that her roe was different in a sma number of significant ways. She devoted ess time to direct patient-facing cinica activities (she did not work cinica shifts), she did not spend time sociaising with patients and getting to know them or their backgrounds and she did not work extended hours. Her summary comments were: I found this very stressfu, and wonder, is this person an adrenaine junkie? She is very caring, but I woud question her need to be at work six days a week, tweve hours a day. It fees ike she is hoding onto a runaway horse by the mane rather than trying to tether and train it. The NHS is hard, and ife on the wards is hard, but she is taking a the responsibiity. We have staff ike her at this trust, too, and their wards fai when they are away. That is not good management. Sorry to be critica. She is obviousy working her socks off but there is an easier way. It is significant that this second matron was critica of the approach of the first, as we as pointing out differences in the way they had each crafted their respective roes. A matron's roe is fexibe and senior enough to aow for this degree of individua job crafting. Ceary this is not possibe in a roes, but is ikey to be the case for many hybrids. Not noted in this discussion is the way in which a matron's roe overaps consideraby with that of a ward sister, whose profie wi share many of the characteristics shown in Tabe 25. Many if not a of the non-cinica dimensions of a matron's roe aso overap with those of an operations or a genera manager. Job crafting may address individua motives and preferences whie creating roe overaps and potentia confusion. Finay, the second matron's criticisms refect earier discussion concerning the desirabiity of and necessity for extreme jobs. This appears to be an under-researched area. Concusions and impications: reeasing time to manage There's no time for extra projects and that sort of thing, which is a shame. So you're just doing your day job, there's no time... you don't get a chance on any working parties for progression and that sort of thing. I don't think we do enough forward panning. Because we haven't got the time to do that. Whie you recognise that, yes, this is a firefighting type of job, and it is reactive as opposed to proactive, I'm sure, we, in fact I know, that if we had more time to pan, we woud do things differenty, and a bit more efficienty. Operations manager, Cearview The combined weight of evidence from past research and from this project suggests that midde managers pay key roes in maintaining operations, mediating between the front ine and top team, deveoping 56 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 innovative service improvements and heping both to shape and to impement strategy. Further evidence concerning midde management contributions is expored in the foowing chapter. Midde managers appear to be deepy committed to the service and its patients, and highy motivated to make a difference. The motivationa profie incudes hygiene factors but is dominated by themes that woud be cost neutra to strengthen, such as teamwork, recognition and autonomy. However, the evidence aso portrays a group that is facing increasing workoads, decreasing resources, tighter reguation and more onerous performance expectations. Athough having the ideas, this group acks not ony the resources but aso the authority, senior management support and the time to deveop them. One initiative that has seen widespread appication in acute trusts is the Productive Ward, an initiative designed by the NHS Institute for Innovation and Improvement. The aim of this initiative, with regard to nursing staff, concerns reeasing time to care. It woud therefore be usefu to consider ways of reeasing time to manage. Asked in focus group discussions to identify steps to achieve this, midde managers offered the foowing suggestions: What can I do? wak the foor, tak to peope, don't be driven by e-mais make time for refection, create space where probems or issues can sit, for exampe on a whiteboard in an office peope can visit and offer thoughts and suggestions. What can we do at directorate eve? ensure that staff are prepared in advance for performance review meetings; rehearse rapid improvement events, step back, time out to refect on what we are doing reease time at the mid-eves, office days, fewer and shorter meetings. What corporate actions woud hep? cinica director and directorate manager make a powerfu team deveop this potentia give managers timey and understandabe financia information empower ward sisters to manage their wards effectivey we have potentia at a eves that we need to tap into make it safe to chaenge; the attitude, I'm ony a porter, needs to be repaced. These suggestions are offered here for three reasons. First, they demonstrate that the constraints on midde managers are widey recognised. Second, they indicate that there are many, simpe, practica steps that coud begin to address this issue. Third, they serve to introduce the concept of an enabing environment a supportive context for management work and this concept is expored in more detai in Chapter 4. The NHS has a motivated and committed midde management popuation. Given the motivationa profie, most of the actions necessary to sustain and to strengthen motivation and commitment are cost neutra. Midde managers are a key source of new ideas and innovations for service improvement and deveopment. The workoad, time and other organisationa constraints under which they operate stife their abiity to impement those ideas. The midde management popuation is thus in danger of becoming an underutiised, misused, wasted and potentiay wasting asset. Research priorities Management capacity This anaysis of the reaities of midde management indicates two research priorities. One concerns the question of management capacity, which was discussed in Chapter 2. The expectations and demands paced on midde managers in the acute sector pure pays and hybrids have increased, and in the context of Queen's Printer and Controer of HMSO 2013. 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. 57

THE REALITIES OF MIDDLE MANAGEMENT current heath-care poicies those expectations and demands are ikey to continue to increase. Were the traditiona acute trust mode to come under more pressure, triggering a wave of mergers, takeovers and accompanying service reconfigurations, 179 and if the reguatory regime were to become stricter and more invasive, 180 midde managers woud once again be in the front ine of responding to those chaenges in addition to the existing management agenda. During this project, as indicated previousy, the manageria resources avaiabe to acute trusts were themseves being reorganised, streamined and reduced. This was increasing the manageria responsibiities of hybrids, many of whom had itte or imited manageria experience or education. Urgent research questions thus incude: 1. How shoud management capacity be understood, defined and assessed? 2. How can an acute trust determine whether or not management capacity is adequate in reation to the agenda that it faces? 3. How can management capacity be sustained and strengthened in the context of ong-term financia and reguatory pressures? Extreme jobs The concept of extreme heath-care management jobs has face vaidity and has a degree of support from the quaitative and survey evidence generated by this project. The motivationa profie that accompanies extreme jobs in acute settings aso seems to have distinct properties. Extreme jobs may not be probematic. Many high performers enjoy the pace and chaenge and are attracted by the intrinsic and extrinsic rewards that such roes can provide. But the ong hours that extreme jobs entai have predictabe consequences for stress and work ife baance, and can reduce individua performance and increase the incidence of mistakes. In particuar, for a hybrid who combines manageria and cinica responsibiities, the negative impications of an extreme job coud potentiay jeopardise patient safety as we as persona we-being. These observations are specuative, extrapoating from the preiminary concusions of this project, and are not stated here as firm caims. However, given what we know about other trends affecting midde managers, a further specuation is that some extreme jobs are ikey to become even more extreme. Urgent research (and practica management) questions thus incude: 1. Is there a distinct extreme jobs pattern among midde (and senior) managers in heath care in genera, and in the acute sector in particuar, with an accompanying motivationa profie? 2. How widespread is this pattern among pure pays and hybrids, and how does the baance of advantages and drawbacks infuence individua and unit performance? 3. If the incidence and consequences of extreme jobs are on baance probematic, how can such roes be redesigned (job crafting and i-deas) so that they are ess extreme, or are positivey extreme, and what additiona supports can be provided for those in extreme jobs, and for hybrids in particuar? 58 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Chapter 6 Managing change foowing extreme events Making change happen is chaenging when peope do not have any sense of having been part of the probem (Chief executive, acute trust) What's the probem? Managing serious incidents What are we good at? The hospita investigates thoroughy. It is good at identifying incidents, and beginning investigations quicky. Assistant director, Burnside If the issue is cinica, and confined to a specific area, we hande it we. We had a never event recenty, where a nasogastric tube was inserted incorrecty into a patient's ung, and this wasn't picked up on the x-ray. This incident ed to a compete change in process, and we've sorted this now to the extent that the probabiity of this happening again is very ow. Genera manager, South Netey Rigorous anaysis a staff are trained in root cause anaysis techniques; exceent systems and tempates to ask the correct questions and a team approach to probem soving. And no bame; peope can earn without the fear of being bamed. However this does not suggest that peope are not hed to account. Operations manager, Cearview What are we not good at? Good at finding out what happened, but sippage then foows. The hospita needs to earn how to manage the ong tai of the process. Medica director, Burnside We're not effective at cascading the earning. Investigations are handed at a high eve, and things don't aways get back to the front ine. Matrons and ward managers are invoved in the incident, but the root cause anaysis is ifted out of their area. Someone wi come and say, we need a statement from you. Nursing staff fee terribe about this because they're made to fee guity, and the process isn't expained to them. Genera manager, South Netey Queen's Printer and Controer of HMSO 2013. 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. 59

MANAGING CHANGE FOLLOWING EXTREME EVENTS We are ess good at foow-up action. We are great at putting out the fire. I don't think that we are as good at finding out what caused the fire we are great at producing an action pan that says what the issues are and what we are going to do, but we are ess good at keeping hod of it, not etting it drop off the agenda. Assistant director, Cearview Serious untoward incidents and never events are typicay foowed by an investigation to estabish root causes and to recommend actions to prevent further incidents. However, receptiveness to change cannot be guaranteed, and recommendations are often ignored. One exampe of such faiure to change concerns the death of 17-month-od Peter Conney in 2007. 181,182 Previousy, in 2000, 8-year-od Victoria Cimbié had been kied by her guardians in the same London borough, Haringey, where Peter ived. In a 400-page report with 108 recommendations, the pubic inquiry (chaired by Lord Laming) into Victoria's death had previousy bamed systemic faiures among the agencies responsibe for monitoring vunerabe chidren: the oca authority, socia services, the NHS, the poice. 183 In 2008, Laming noted that many chid protection agencies had ignored his recommendations, 184 saying that, I despair about the organisations that have not put in pace the recommendations which I judged to be itte more than good basic practice. Inquiry recommendations typicay estabish defensive change agendas, aimed at preventing particuar behaviours and events. Defensive agendas are ess interesting and more chaenging to impement than progressive agendas, which focus on making things happen. 185 Terminoogy surrounding events such as these is varied: accident, adverse event, catastrophe, crisis, critica event, deviance, disaster, error, faiure, misconduct, mistake, near miss, never event, non-conformity, sentine event, serious incident, vioation. For the purposes of this report, we wi use the term extreme event as the category abe. We wi consider four extreme events. Case seection criteria incuded management recommendations and access to staff and documentation. Interviews were based on a topic guide (see Appendix 2) and, despite the sensitive nature of these issues, participants wecomed the opportunity to discuss their experiences with a researcher. Donadson 21 distinguishes between passive earning (identifying essons) and active earning (impementing changes). The interview quotes opening this chapter indicate strengths in the former and weaknesses in the atter. Given our imited understanding of the factors that impede active earning, this study sought to understand: the conditions that respectivey enabe and constrain the diffusion, impementation and embedding of changes foowing extreme events the support, toos, frameworks and guideines that woud strengthen change management capabiity in such contexts. The main concusions from this chapter are that: Extreme events proceed through broady comparabe phases. The weight of research and commentary ies with the pre-crisis, event and crisis management phases. The post-crisis phase impementing change has attracted ess attention. Foowing an incident, three inter-reated issues become significant: causaity (why did this happen?), agenda (organisationa earning and recommendations for change) and process (change impementation). The causaity of extreme events is usuay compex, invoving the combination and interaction of numerous factors, at different eves of anaysis, over time. There is a need for mutieve, sociotechnica expanations of extreme events, eading to mutieve systemic agendas for organisationa change. The context for change foowing an extreme event can be described as a wicked situation, deaing with severa inter-reated contributory factors, in the absence of stakehoder consensus, and in which the rues of participative change management no onger appy. 60 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 The effective management of sustainabe post-event change invoves the deveopment of context-sensitive approaches that address systemic organisationa issues, with a progressive agenda, engaging staff invoved and addressing conficting perspectives. In addition to evauating compementary methods of incident investigation, research shoud seek to evauate appications of high-reiabiity organisation concepts in acute care settings. The management of extreme events Figures pubished yesterday by the Nationa Patient Safety Agency show that more than 5,000 patients died or were seriousy injured as a resut of NHS safety incidents in the six months to March 2011. A tota of 1,313 peope in Engand and 78 in Waes died as a resut of medica errors invoving the care they received from hospitas, menta heath trusts and ambuance services. A further 3,699 patients in Engand suffered severe harm permanent harm, incuding disabiity and scarring. NHS Confederation press summaries, 14 September 2011; www.nhs.confed.org Foowing a number of high-profie service faiures, patient safety has become a nationa priority. 99 From 2003, a vountary reporting scheme, the Nationa Reporting and Learning System (NRLS), operated by the Nationa Patient Safety Agency (NPSA) has been in pace. This invited heath-care organisations to report serious untoward incidents. Serious untoward incidents are events ikey to cause significant harm to patients, members of the pubic or staff and that coud aso cause disruption to the service and damage the reputation of the organisation and/or its empoyees. Never events (25 are designated) are a category of serious incidents that shoud not occur if preventative measures are in pace (e.g. wrong site surgery, misidentification of patient). In Apri 2010, reporting became mandatory. The increase in the number of incidents submitted to the NRLS between 2003 and 2010 can be expained by the growing percentage of heath-care providers submitting monthy reports (1% in 2004; 81% in 2009); around one miion incidents are now reported annuay. In 2009, athough most incidents caused no harm, 3735 were reported to have caused death (NPSA Quartery Data Workbook: www.nrs.npsa.nhs.uk/resources). Washe and Higgins 186 date the increase in inquiries into major service faiures from the Ey Hospita scanda in 1967. Recent events at Mid Staffs have aso been subject to severa investigations. 70 Some of these serious untoward incidents ead to compensation caims. Estabished in 1995, the NHS Litigation Authority (NHSLA) handes caims against the NHS, administering the Cinica Negigence Scheme for Trusts (CNST) and managing non-cinica caims and the iabiities to third parties scheme. Tabe 26 shows the numbers of caims received since 2004 and the payments made against them. 187 The tota cost of caims was amost 800M in 2010 11, more than doube the cost in 2004 5. By 2012, a typica settement for a catastrophic injury caim was 6M. The NHLSA attributed these rising costs to TABLE 26 UK CNST caims and payments, 2004 10 Year CNST caims received Payments on cinica caims ( 000s) Payments on non-cinica caims ( 000s) 2004 5 5609 329,412 25,119 2005 6 5697 384,390 31,278 2006 7 5426 424,351 33,883 2007 8 5470 456,301 27,715 2008 9 6088 614,342 37,890 2009 10 6652 650,973 40,376 2010 11 8655 729,100 42,400 Queen's Printer and Controer of HMSO 2013. 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. 61

MANAGING CHANGE FOLLOWING EXTREME EVENTS the no win no fee market whereby caimants can itigate with no financia risk, and to awyers and agencies farming compaints against NHS organisations. 188 Serious incidents and never events harm patients, disrupt services, damage organisationa reputations and individua careers and can generate heavy costs. There is now a substantia body of work in this area, triggered by the andmark pubication by the US Institute of Medicine, To Err is Human, 189 which estimated the annua cost of heath-care errors (in the USA) to be between $17B and $29B. That iterature is rich in terms of guideines, diagnostics, protocos, checkists and aerts. The main probem, however, appears to ie not with guidance, but with impementation. Much is aready known about the causes and management of extreme events. Crisis management research has mirrored the stages of the event sequence narrative. This typicay begins with the incubation period 190 and associated resident pathogens, 191 foowed by a focus on risk management and emergency panning. 192,193 There is practica crisis management advice, 194 aong with accounts of individua events: the Mann Guch disaster; 195 the oss of the Chaenger space shutte; 196 Snook's account of a fata friendy fire incident; 197 Perrow's studies of norma accidents. 198 Inquiry reports can be seen as proxy research data. 199,200 The deveopment and appication of safety cutures, 201 resiience engineering 202 and high-reiabiity organisation 203 have been advocated as ways to reduce the incidence and impact of extreme events. The dominant perspective in the post-event period views what happens to inquiry recommendations in terms of organisationa earning. 204 A number of commentators have noted the absence of a change management perspective, 40,205 and this is the ens focusing on the design and impementation of a change agenda through which the extreme events summarised in this chapter are viewed. Root cause anaysis (RCA) is the main approach to heath-care incident investigation. RCA tends to focus on immediate and we-understood causes, and can overook wider systemic, contextua and tempora factors. Carro 199 expores the ogics driving incident review teams in nucear power and chemica processing settings, concuding that RCA eads to root cause seduction, by which he means a reassuring preference for simpe and rapid soutions, potentiay overooking the ess obvious and more chaenging systemic roots of faiures. Leveson 206 argues that the emphasis in accident anaysis needs to shift from cause (which has a imiting, bame orientation) to understanding accidents in terms of reasons, i.e., why the events and errors occurred (p. 241). Athough based on research in other sectors, the advice of these commentators appears usefu in examining the reasons behind and the aftermath of the heath-care incidents discussed ater in this chapter. Current approaches to accident modeing aso rey on systems-theoretica perspectives, 207,208 rather than domino and Swiss cheese modes. Rasmussen 209,210 observes that, athough incidents may be caused by oss of contro of work processes, other factors are invoved in safety contro. Figure 4 depicts what Rasmussen 209 cas the probem space (p. 185), identifying the mutipe ayers of contro that are often impicated in accident causation, the discipines associated with their respective study and environmenta stressors such as changing poitica cimate, pubic expectations, financia pressures, changes in education and competencies and the pace of technoogica change. This generic mode seems to be reevant to UK heath care, particuary with regard to system ayers and environmenta stressors. An accident scenario can be represented by an accimap showing how events and conditions interact, reveaing the pattern of antecedents, causaity and consequences. Figure 5 shows an accimap for the case of Mrs Mayand (discussed ater). Athough difficut to read in this format, this iustrates the compex causaity behind this patient's death, and the inks between different ayers of anaysis over time. Athough this patient died from a prescribing error, the accimap aso captures the roes of reguatory bodies, organisation and management, infrastructure and processes and procedures. Rasmussen 209 argues that such incidents have not been caused by a coincidence of independent faiures and human errors, but by a systemic migration of organisationa behaviour toward accident under the infuence of pressure toward cost-effectiveness in an aggressive, competitive environment (p. 189). Individua 62 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Layers of contro Government Reguatory bodies Organisation Management Staff Working practices Environmenta stressors Changing poitica cimate and pubic opinion Changing market conditions and financia pressures Changing competency and eves of education Fast pace of technoogica change FIGURE 4 The probem space: sociotechnica system risk management hierarchy. Based on Rasmussen, 1997. 209 decision-makers don't see the compete picture and are not abe to judge the state of defences, which depend on decisions taken by others esewhere. The systemic nature of serious incidents in heath care is refected in the London protoco, which identifies the hierarchy of factors infuencing cinica practice: institutiona context, organisation and management factors, work environment, team factors, individua (staff) factors, task factors and patient characteristics. 211,212 Athough this protoco underpins RCA training, the process and outcomes of investigations based on this approach do not aways refect a systems perspective. Nicoini et a. 213,214 identify barriers to earning from RCA investigations. Investigations are conducted by staff who were not invoved in the incident and who continue with their fu-time roes. Interrogating witnesses, coating and anaysing evidence and drafting recommendations can be a compex and protracted process. Outcomes are often infuenced by time constraints and ack of expertise. Tensions are generated by the need to make service improvements in the face of imited resources, competing priorities and conficting views. They found that investigation reports often focused on oca cinica practices and context, and they aso note that many potentia root causes were discounted in the anaytica process, often based upon the assumption that such atent factors were not easiy resoved or because the compexity and ambiguity of the issue woud not aow it to be resoved with a singe, ceary containabe countermeasure (p. 37). 213 Patterns and trends in incidents were rarey considered and the investigation report was often seen as an end in itsef. The need to produce an acceptabe pan focused attention on avaiabe soutions and minor improvements, rather than on organisationa changes with substantia resource impications. This study concuded that risk managers and investigation teams acked a coherent orientation towards managing change (p. 39), for which the typica strategy meant designating a cinician responsibe for the action pan, and checking progress some months ater. Impementation issues such as faciitating change, addressing resistance and inking to other initiatives were rarey considered. The four incidents that foow iustrate many of these issues, confirming aspects of the nature of investigation processes and reinforcing the barriers identified by Nicoini et a. This anaysis aso points to ways in which RCA methods coud be compemented by other toos and perspectives, to increase the probabiity of effective and more rapid changes fowing from such events. Costridium difficie at Burnside In contrast to the incidents that foow, the way in which Burnside managed a serious outbreak of C. difficie was a success. This incident was expored, at the chief executive's suggestion, to expain that success. The resutant approach is termed a maintenance mode, because the actions necessary to prevent a recurrence of a crisis such as this are quite different in nature and timescae from those actions that were Queen's Printer and Controer of HMSO 2013. 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. 63

MANAGING CHANGE FOLLOWING EXTREME EVENTS Leve Description Time Mrs M. Cearview: reason L1 Society, pubic L2 L3 Government Reguators, associations NPSA aert review oca action, software and purchasing to distinguish between 2.5-mg and 10-mg tabets NPSA guidance focused on correct dosing not interactions Audit Ony 23% nurses knew about restrictions on methotrexate Ony 17% prescriptions competey correct Regiona rheumatoogy guideines warn about methotrexate and trimethoprim interaction BNF does mention Trimethoprim avoid concomitant use Mutidiscipinary care pans and pathways increase buk of case notes L4 L5 L6 L7 L8 Organisation Management Vagina hysterectomy 1999 Peope Infrastructure, equipment Procedures, processes Junior doctors encouraged to use BNF Patient with medica probems (bone marrow faiure) being on surgica speciaity ward Prescribed methotrexate 2000 Inquiry 2000 Death of patient with rheumatoid arthritis due to methotrexate prescribing errors Mrs M. deveoped severe rheumatoid arthritis 2000 Deayed bood tests Enroed in a tria for new drug combination Junior doctors faied notice fu bood count was not avaiabe Training on drugs and side effects Bood in urine detected Doctors and pharmasist to discuss interventions that had mayor significance or ife threatening Referred for utrasound Improve systems to ensure repeat sampes are faster Consutation in outpatient cinic recommended that ovarian cysts are removed aparoscopicay Medicine Matters Buetin check for toxic drug interactions 2004 Patient progress to be reviewed against admissions diagnosis Kidneys and badder fine. Incidenta ovarian cyst detected Consutant gynaecoogist Patient s own drug ocker/ reminder sticker on restricted drugs Not given the option to do nothing Biatera uretic damage is extremey unusua Independent and drove hersef to hospita...we do not beieve those invoved in the consent procedure adhered to the Trust s poicy Recommended exporing ways of buiding methotrexate issues into training of existing medica staff Lack of eadership in consutant supervision Surgery, 27 June No supervision from consutant abdomina surgeon Catheter sti in situ, experiencing abdomina pain...methotrexate guideines are ambiguousine 10 The dermatoogy, rheumatoogy or gastroenteroogy departments wi supervise treatment... where as ine 40 page 22 the doctor who prescribes the medication has the cinica responsibiity for the drug and the consequences of its use No consutant uroogy or gynaecoogy input Insensitivey handed her husband had recenty died there Wind diagnosed Readmitted, 3 Juy Trust poicy notes such a combination SHOULD be avoided (note not MUST) District nurse Locum surgica speciaist registar Engaged by the trust for ony 1 week Conducted out of hours Surgery, 4 Juy Peritonitis diagnosed...responsibe for the safe use of methotrexate seemed to transfer to a number of different surgica teams and ward pharmacists Pans to discharge to oca hospita Moved to uroogy ward Surgery, 5 Juy Junior staff particuary in orthipaedics appeared unfamiiar with the management of an i oder patient Vomiting and diarrhoea suspected C. difficie Biatera ureteric damage from origina surgery diagnosed (CT scan) in appropriate, incompete and poory supervised courses of antibiotics Prescribed cipfoxacine (antibiotic) Wheeed roator frame was getting stuck...considerabe confusion over who was actuay responsibe for Mrs M. (medica or speciaist surgica team) Services were norma for a bank hoiday Fe in toiet and fractured hip 20 August Prescribed trimethoprim (antibiotic) Top hip repacement Low white ce and neutrophi count 30 August Surgery, 22 August Quite simpy the medica records are by a ong way the most disorganised with have ever encountered in an Inquiry 27-hour deay for bood tests unexpained No medica review 27 and 28 August Prescribed 2 units of bood 1 September...there is no point in the Trust producing poicies and guideines if they are not in daiy use; despite the existence of a poicy it was not foowed, with fata resuts Mrs M. died age 73 years 3 September 2005 Septicaemia Moved to neurocritica care unit Prescribed foinic acid and GCSF 1 September FIGURE 5 Accimap of the Mrs Mayand incident. BNF, British Nationa Formuary; CT, computed tomography; GCSF, granuocyte coony-stimuating factor. 64 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 required to contain the crisis in the first instance. In other words, the maintenance phase of the event sequence, after the immediate crisis was over, was as important as the initia crisis management and emergency response. How did this incident arise? The factors contributing to the outbreak are summarised in Tabe 27, which, athough not foowing precisey the mode in Figure 4, iustrates the mutiayered nature of the probem. Tabe 28 extends that pre-crisis context, identifying the subsequent main phases in the event sequence narrative for this incident, and tracking the impact on C. difficie infection rates. During the pre-crisis incubation period the infection rate of up to 30 a month was perceived as norma and, athough this was a known probem, this did not trigger any specia action. This changed when, in June 2007, nationa tabes identified Burnside as having one of the worst C. difficie infection rates in Engand; as one staff member noted, boody he we're in the bottom ten. This observation did then trigger a rapid emergency response, the detais of which are shown in Tabe 29. The hospita's success appeared to be due to the impact of a combination of actions managed as an evoving programme, constituting a package dea, in contrast with traditiona stepwise change impementation guideines. This six main components of this package incuded: 1. A turnaround team: a cross-departmenta cinica and manageria group with authority to act without further permission from senior managers. 2. Appraise and prioritise: rapid decisions on immediate actions, deayed action on more difficut and sensitive issues. TABLE 27 Pre-crisis: factors contributing to the Burnside C. difficie incident Factor Nature Impications Environment C. difficie strains vary by ocation Loca variation in infection Technica Government targets Deveopment of broad-spectrum antibiotics Low-grade paper towes Inconvenient ocation of basins Focus attention on monitored activities Reduce heath risks by prescribing bacteria infection contro drugs no need for targeted prescriptions Increased possibiity of antibiotic-resistant microbias Ineffective hand washing Organisationa Functiona sios Incidence of C. difficie not communicated Manageria Processes Weak reporting ines of infection contro team Poor governance structures No monitoring or communication of HCAIs Unco-ordinated patient movement and infected patients not isoated Limited patient screening Libera use of broad-spectrum antibiotics Inappropriate dress code Variabe hand-washing regime No corporate awareness of C. difficie rates Low awareness and poor auditing of responses No ownership of HCAI issues No comparison with other hospitas Limited resource for infection contro team HCAIs given ow priority Increased potentia for cross-infection Risk of cross-infection Lack of awareness of carriers Deveopment of antibiotic resistance Impede effective hand washing HCAI, heath-care-acquired infection. Queen's Printer and Controer of HMSO 2013. 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. 65

MANAGING CHANGE FOLLOWING EXTREME EVENTS TABLE 28 The Burnside C. difficie crisis management timeine Phase Key features C. difficie rate Pre-crisis Probem understood but toerated 20 30 cases a month No sense of crisis Perceived norma Limited action isoation unit opened 2007 Increases to 47: November 2006 Crisis Rated one of the worst hospitas in Engand Boody he we're in the bottom ten : SHA support team offer advice June 2007 Emergency response CEO signas top priority Rate reduced to 15 cases a month: Powerfu turnaround team estabished August 2007 Prescribing poicy changed Additiona resources and faciities Corporate reporting for infection contro Maintenance Team continues to meet Spectacuar improvement : June New procedures, screening programme 2008; consistenty 0 5 cases a month: October 2009 New faciities, improved environment Staff training, dress code Patient tracking software deveoped Creative change agenda SHA visits in 2008 note improvements CEO, chief executive officer; SHA, strategic heath authority. 3. Emergency response: quick demonstration that the probem was understood and was being addressed; autocratic, no questions no negotiations stye; poitica fix to reassure externa stakehoders as we as rea fixes to resove the probem. 4. Systemic soution: systemic probems need systemic soutions, incuding individua, team, organisationa, financia, infrastructura and other factors; in addition to many changes in working practice, communications were frequent, authoritative and appeaed to professiona vaues rather than externa targets. 5. Measure and report progress: infection rates were monitored and pubished; a staff were made constanty aware of performance on key metrics; continuing success motivated staff to maintain the trajectory. 6. Pan for continuity: crisis over, is the turnaround team redundant? No; the team continues to work, maintain focus on the agenda, maintain and improve reduction in infection rates the shift from emergency response to maintenance phase was critica to success. The number of new cases fe beow 15 a month in August 2007, and by the end of 2009 the rate was between zero and five new cases a month; that rate has been maintained since (Figure 6). What works in one setting wi not aways work esewhere. However, this anaysis suggests that changes can be impemented rapidy through a combination of compeing evidence, autocratic management (where appropriate), a powerfu cross-functiona management team and innovative communications that encourage behaviour change by addressing beiefs and vaues rather than focusing on externay imposed targets. This combination of actions, incuding a constanty changing change agenda (to combat the infection contro fatigue identified by an infection contro nurse), accompanied by attention to sustainabiity was 66 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 50 45 40 35 30 25 20 15 10 5 0 Number of cases per month Mar-06 Jun-06 Sep-06 Dec-06 Mar-07 Jun-07 Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-11 Sep-11 Month FIGURE 6 Costridium difficie infection rates at Burnside, December 2005 September 2011. successfu both in the short term and in the ong run. This was not a quick fix approach to crisis management. The Burnside maintenance mode is consistent with the systems approach outined above, and offers a practica framework that coud be adapted by other provider organisations faced with simiar difficuties. Mrs Mayand The incident invoved the death of a patient... a cataogue of errors, but the fina eement that caused her death was being prescribed two drugs that interact with each other, and the resuts weren't picked up quicky enough and then acted upon. She died just over a week after the drugs were administered. A cataogue of errors up to that point with peope not knowing who's in charge and not being cear. But as with a of the most serious untoward incidents, there was a sort of an opportunity, amost up unti the ast few hours when it coud have been turned around. Associate director, Cearview Mrs Mayand attended Cearview for a hysterectomy in 1999 which wi be taken as the starting point for this incident timeine. In 2000, she deveoped severe rheumatoid arthritis and was enroed in a tria for a new treatment regime that incuded methotrexate, a high-risk drug. In 2000, another arthritic patient at Cearview died as a resut of a methotrexate prescribing error. The inquiry noted that this was a medica patient on a surgica speciaty ward, bood tests had been deayed and junior doctors did not notice that a fu bood count test resut was not avaiabe. An audit found that ony 23% of nurses knew about restrictions on the use of methotrexate, and ony 17% of prescriptions were competey accurate. Training and drugs poicy were to be revised. Whie Mrs Mayand was taking part in the tria, bood was detected in her urine, and an utrasound scan detected a arge ovarian cyst. In spite of her arthritis, she drove hersef to Cearview for eective surgery on 26 June 2005. She never eft the hospita aive. She was referred to a consutant gynaecoogist who removed the cyst aparosopicay. Shorty after that procedure she suffered abdomina pain and faiure to pass urine. Biatera ureteric damage from the surgery was identified and corrected. She was then to be discharged to another hospita, which caused distress as her husband had recenty died there, so she remained at Cearview. The subsequent inquiry suggested that she shoud have been given the option to return home, and one interviewee noted that, at this point, she neary escaped us. However, she contracted a C. difficie infection from which her recovery was sow. She was then given a fauty roator (a wheeed waking frame) and fe and fractured her hip; a tota hip repacement had to be performed. For this Queen's Printer and Controer of HMSO 2013. 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. 67

MANAGING CHANGE FOLLOWING EXTREME EVENTS TABLE 29 Burnside management response to the C. difficie incident Factor Actions Consequences Environment Simiar incident had occurred in a nearby hospita Management aware of wider probem and impications Nationa eague tabes show comparativey poor performance SHA sends team to investigate and support Seriousness of probem exposed seen as at crisis eve Guidance, support, egitimacy for radica actions and investment Financia Immediate additiona funding New isoation unit Increased recurring budget More resource for infection contro Isoation bays in wards Increased space between beds Technica Upgrade hand towes Improved hand hygiene Upgrade hand-washing faciities Increased rates of hand washing Organisationa Create C. difficie turnaround team Integrated cross-functiona working-focused activities Change reporting ines for infection contro to director of nursing and chief executive Doube the size of infection contro team Create and staff dedicated C. difficie isoation unit Direct access to executive management group and board Highight importance of HCAIs Skied staff caring for patients; patients segregated to reduce cross-infections Manageria Chief executive and board own HCAI rates Coective hospita-wide ownership of HCAIs Communication appeas to persona and professiona vaues Chaenge behaviours (e.g. hand hygiene); confront resistance to change (e.g. prescribing practices) Significance of HCAIs widey understood Commitment to change Process Amend dress code A ead to reduced cross-infection Training increased Deveop manua of practice Daiy ward rounds by infection contro nurse and pharmacy staff Routine patient screening Individua Choice of autocratic change agent Direction and energy HCAI, heath-care-acquired infection; SHA, strategic heath authority. procedure she received the antibiotic trimethoprim, which interacted with the methotrexate. Her bood count began to show a ow white ce and neutrophi count. Cinica and nursing records show deays in conducting bood tests and ack of attention to her deteriorating condition. Mrs Mayand died on 3 September 2005. The incident timeine ran for 11 years, from 1999 to 2010, when a fina review of the origina inquiry recommendations was conducted. The post-event segment of the incident timeine asted for 5 years and is summarised in Tabe 30. This incident had a profound effect on the trust. It ed to the estabishment of a Patient Safety Executive and the deveopment of a Patient Safety Unit reporting to the trust quaity committee, a safety first programme with a new patient safety strategy and a more proactive approach to safety issues with Cinica Area Safety Assessments (CASAs) of cinica processes. Patient safety became an important board agenda item, aong 68 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 30 Mrs Mayand post-event timeine Date 3 September 2005 27 September 2005 Immediate changes January 2006 Juy 2006 September 2006 March 2007 January 2008 September 2010 Event Mrs Mayand dies, age 73 years causes of death incuded septicaemia and bone marrow faiure due to the interaction of methotrexate and trimethoprim, compications arising from previous surgery and faiure to act on an abnorma bood test resut Assistant director of risk meets with famiy; seven members of inquiry pane agreed chairperson, chief nurse, associate director pharmacy, consutant obstetrician, consutant histopathoogist, non-executive director, famiy representative with background in heath care (and advice from pharmacoogy professor); 30 members of staff are interviewed and statements taken Structured daiy shift report instituted, training on medica eary warning system formaised on wards, review of safe prescribing of methotrexate, roe of senior cinica nurse atered to ensure greater cinica profie New methotrexate poicy and procedure Inquiry report pubished 122 pages, 46 recommendations; steering group estabished with acting chief executive, director of operations, director of administration, chief nurse, medica director and governance manager Trust response to inquiry report pubished; steering group's remit is to oversee impementation of inquiry recommendations: report is widey disseminated to staff; recommendations aocated to four working groups: medica records and documentation, medicines management, inpatient care and requesting and reporting bood tests other recommendations addressed by key individuas Inquiry recommendations progress report: 30 pages Inquiry recommendations fina report: 17 pages Inquiry recommendations fina report: 21 pages with patient stories. One of the roes of the Patient Safety Unit was to pursue recommendations that had not been fuy resoved. The inquiry report in 2006 made 46 recommendations. By the end of the first quarter of 2010, 4.5 years after Mrs Mayand's death, 31 of those recommendations had been competed and cosed, six were competed but with remaining issues and nine were unresoved and open. In other words, two-thirds of the recommendations were considered to have been impemented in fu, with one-third outstanding or requiring further work. What is the expanation for that tai of issues? Tabe 31 summarises the 31 recommendations competed by September 2010. Organisationa changes often generate probems, but in this instance creating a new unit, hiring more staff, streamining processes, providing more training and nominating methotrexate days coud be regarded as ow hanging fruit, and hardy ikey to trigger resistance. One interpretation, therefore, is that recommendations that were simper and quicker to impement were tacked first. Do the recommendations that had not been impemented fuy dispay any common properties? The six items identified as competed but with issues were: despite review, the content and structure of medica records were sti unsatisfactory despite deveopment of new nursing care pans, new forms and pans that were outside the agreed process were being added to notes the ALERT (acute ife-threatening events recognition and treatment) sheet had been revised and, athough this was in use for 90% of patients, ony 10% of these were competed accuratey despite the introduction of standardised patient observation charts, there were many different charts in use across the trust, with some areas using an eectronic system Queen's Printer and Controer of HMSO 2013. 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. 69

MANAGING CHANGE FOLLOWING EXTREME EVENTS TABLE 31 Recommendations competed and cosed by September 2010 Theme Guideines, poicy document, information sheets, forms: revised methotrexate ALERT sheet, guideines for inpatient management, poicy on drug interactions, information sheets, prescription charts Organisationa changes: new edery trauma unit with two extra consutants, new consutant microbioogist, breast surgeons removed from genera surgery on-ca rota, revised pharmacy system for urgent requests, medicines management formaised in nursing handover, improved nursing eadership on one ward, more frequent coection system for urgent bood tests, Monday and Tuesday are designated methotrexate days Number of recommendations 17 8 Patient monitoring systems: identifying and monitoring methotrexate patients 3 Training: deaing with abnorma bood test resuts and ALERT and ALS for junior doctors 2 IT: new computer system indicating ocation of drugs not hed centray 1 Tota 31 ALS, advanced ife support. procedures for requesting repeat test sampes had been defined but resuts were not recorded appropriatey, and many resuts were not recorded in the medica records at a the management of deteriorating patients was part of the medica eary warning system (MEWS) with which the trust was 85% compiant, but care of deteriorating patients on genera wards was sti a cause for concern. These items appear to concern the reuctance of staff to abandon the od variety of systems, procedures and working practices in favour of new standardised processes. There were a further nine items one-fifth of the recommendations sti open at the time of the review in 2010, summarised in Tabe 32. With the exception of the ward pharmacists' issue, the open items concern the non-compiance of cinica (mainy medica) staff with new systems, procedures and other working practices, and with what appear to be attempts to standardise procedures in the interests of consistency and predictabiity. The progress pattern can thus be expained as foows: issues resoved: easy to impement changes such as revised guideines issues partiay resoved: staff using od systems and practices rather than switching to new issues unresoved: medica staff reuctant to adopt standardised procedures. There had been considerabe progress. The management of patients on methotrexate and mutidiscipinary teamworking had been improved, and education packages for doctors in training had been revised. Nevertheess, in 2010, prescribing errors were being reported at a rate of 150 a month, and between January 2005 and May 2012 the trust ogged 210 incidents (none serious) specificay invoving methotrexate, with some of those incidents aso invoving trimethoprim. At around 10M for a trust-wide system, the cost of eectronic prescribing was prohibitive. The 2010 review noted that, athough one feature of Mrs Mayand's case was faiure to act on a bood test resut, resoving abnorma resuts has been far more chaenging than originay anticipated and recent incidents identify that this remains a significant issue. It thus appears that the competed with issues and open recommendations concerned actions that had been mandated, but not managed managed in the sense of estabishing the benefits to staff, gaining agreement and commitment, invoving those affected in impementation, tacking resistance, reguary monitoring progress and preventing or inhibiting the use of the previous systems and practices that 70 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 32 Recommendations unresoved and open in September 2010 Recommendation Review consutant gynaecoogists' operations Improve cross-referra between speciaities Famiies shoud be offered choice on discharge Those ordering tests shoud ensure that a fai-safe mechanism is in pace for reviewing resuts Better medica handover at nights, weekends and bank hoidays Communicate abnorma bood resuts directy to doctor in charge Ensure that posts are training posts and not cinica feow posts Reguar ward rounds and cover for surgica patients with compex conditions Review ward pharmacist roe to focus more on cinica activity Status High standard of care but no database to record outcomes and compications; unresoved Not impemented, work to be done to improve quaity and consistency of handovers Disagreement regarding discharge ocation deat with in case conference; the perfect discharge not in pace Revised procedure introduced but not being used, handover of cinica information remains a concern and medica records are often of a poor quaity New guideines in medicine division but handover takes a different form with different IT support in each area Revised procedure introduced but not fuy used, with ony one-quarter of resuts recorded in abnorma resuts book Sti a mixture of training and non-training posts, and difficuties recruiting and retaining medica staff Medicine directorate guidance on ward rounds in pace, guidance on compex care under deveopment; increase in number of consutanted ward rounds, but impact is indeterminate because of inadequate note keeping Teamwork supporting inexperienced staff, but ward pharmacists sti have non-cinica duties and do not work a 7-day week were being repaced. In sum, an orientation towards managing change seems to have been absent in this instance. 213 Mr Torrens Mr Torrens came to the emergency department at Cearview ate in the evening of 30 December 2010 having taken an overdose of co-codamo tabets earier in the day. A young man, with a ong history of depression and anxiety attacks, he had attempted suicide in 2005 with an overdose of paracetamo, and had stopped taking antidepressants 2 months before this atest incident. He was admitted to the Cinica Decisions Unit (CDU). He was co-operative during his initia assessment, based on a prompt for menta heath/suicida patients form, which informs cinica judgement but does not provide a risk score. Mr Torrens aso said that, athough he had eft a suicide note, this was an impusive act which he now regretted. By 0530 the foowing morning he was considered to be medicay stabe and was referred for psychiatric assessment. This assessment did not take pace. The on-ca psychiatrist was working at another hospita and his car broke down at 0800. He decided to hand Mr Torrens over to the iaison psychiatry nurse who was due to arrive in the CDU at 0900. Mr Torrens tried twice to eave the CDU. On the first attempt the nurse in charge took him back to bed and the on-ca emergency department doctor noted in the medica record that security shoud be caed if he attempted to eave again. On his second attempt, security was not caed. At 0905 the ward housekeeper noticed that Mr Torrens was not on the ward and informed the nurse in charge who initiated a missing persons search. Attempts were made to contact Mr Torrens by mobie teephone, his parents were advised that he was missing and security and poice were informed. However, at 0915, Mr Torrens was struck by a train on the raiway ine cose to the hospita and died from his injuries. The iaison psychiatry nurse had Queen's Printer and Controer of HMSO 2013. 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. 71

MANAGING CHANGE FOLLOWING EXTREME EVENTS arrived at 0910; she was abe to access Mr Torrens' detaied menta heath records from a ward termina, which acute trust staff were unabe to do. The investigation into this incident identified three root causes: 1. The menta heath assessment performed by emergency department staff did not assess fuy the risks associated with patients iabe to sef-harm. 2. Training to recognise the triggers and behaviours of sef-harming patients was inadequate. 3. Support for patients with menta heath needs in the emergency department was insufficient. Training for emergency department staff in recognising and managing patients with menta heath issues was subsequenty impemented. However, emergency departments can be busy, frenetic environments, unsuitabe for patients who are agitated and suffering from menta heath disorders. However, the third recommendation here was key. Cearview did not empoy on-site psychiatric cover. Psychiatric support was based at another site, with support on ca out of hours. Acute trust emergency department staff did not have eectronic access to menta heath records, and aso acked skis for deaing with menta heath patients. In addition, many patients presenting in an emergency department are inebriated or have taken drugs, and menta heath staff wi not assess under those conditions, waiting unti patients are sober and/or the drugs have ceared their system. This meant that psychiatric assessments were often deayed and patients coud be moved to another unit, with staff ess skied in managing menta heath patients, in order to meet the emergency department 4-hour target. These deayed assessments may have come to be seen as norma: I think it was an accepted part of the emergency department and the CDU. I think it was probaby the thinking oh, it has aways been done this way, aways come here, aways been accepted to keep the menta heath patients, and there has aways been a deay in getting them reviewed or moved to a more appropriate environment. That's how it has been. Senior nurse, Cearview The provision of out-of-hours psychiatric support was a ong-standing concern, with studies suggesting that at east 5% of patients arriving in emergency departments have menta heath probems. Acute hospita patients are coded according to medica condition and not menta state, so that figure may be inaccurate. One interviewee commented: We have had a massive increase, with 18 per cent of peope who sef-harm through drugs mainy because of the cimate we are iving in. Peope are coming in osing their jobs, so menta heath is definitey on the increase. And as a department, we don't reay have that infrastructure. The other probem is [psychiatric support] not being on site. Operations manager, Cearview There had been a simiar incident earier that year, in Juy, when a mae patient in the emergency department became increasingy agitated but his menta condition was not assessed. At nine o'cock in the evening, the patient tried to abscond, stabbed a member of staff with a pen and injured 11 others before the poice arrested him (the menta heath trust having refused to admit him to their unit). He was assessed the foowing morning at the poice station and then moved to a secure menta heath unit. This incident had aso prompted discussion between acute and menta heath trust management, but without progress. Foowing this more recent incident, the management teams from the acute and menta heath trusts met to expore appropriate actions. However, at the time of writing, itte had been achieved: I suppose it was the incident on New Year's Eve that was the absoute organisationa wake-up ca. Having said that, it has been painfuy sow to do anything. I think we have a different view on menta heath to the menta heath trust. Things that cause us angst they do not see as an issue, and I don't 72 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 think they understand why we see it as an issue sometimes. So getting an understanding of what the probems are hasn't been easy because, actuay, what are probems to them are not probems to us, and vice versa. Senior nurse, Cearview There was a shared desire to resove these issues, but no project ead had taken responsibiity. In 2012, the menta heath trust funded a new faciity on the Cearview site, a better environment where their staff coud undertake assessments, but no changes were made to staff numbers or other working arrangements. One soution concerned the appointment of a menta heath nurse or speciaist socia worker based at Cearview. From the acute trust's perspective, however, this invoved covering a staff shortage for the menta heath trust. It was proposed to fund a piot menta heath nurse cover in the emergency department during twiight hours, aong with a new rapid assessment mode. The provision of on-site consutant psychiatric cover was considered to be more difficut to achieve. The main impediments to further change in this case thus appear to concern: two organisations with differing views on the conditions that shoud trigger a psychiatric assessment and the circumstances under which such an assessment shoud take pace ack of funding for additiona staff and the unwiingness of one organisation to contribute to the staff costs of the other menta heath trust concern about triggering confict were they to suggest evening and weekend rotas to staff two organisations with different information systems and separate secure access codes. Patients requiring psychiatric assessment continued to present in the emergency department at Cearview. In 2012, another incident simiar to the case of Mr Torrens occurred, but this was sti under investigation at the time of writing. Mr Mitcham I hate waking the foor now. I see bombs waiting to expode everywhere. Extreme events workshop participant, Cearview Mr Mitcham, 66 years od, came to the Cearview eye unit in October 2011 for cataract treatment invoving the impant of an intraocuar ens under oca anaesthetic. He was the ast patient having this treatment on the afternoon theatre ist and he was patient number 7. However, patient number 6 arrived ate and was not ready for surgery. Mr Mitcham was thus taken into the theatre by the anaesthetic practitioner as the sixth patient. The operating surgeon was not made aware of this change in running order. Beieving that she was operating on patient six, she impanted in Mr Mitcham the ens for that patient, ony reaising the error when competing the operation note after the procedure. The consutant was informed immediatey and Mr Mitcham was taken back into theatre where the incorrect ens was repaced without probem. He was discharged that day and suffered no permanent harm. The hospita serious incident management group decided that this met the criteria for a never event and an investigation was conducted. Why did this happen? The anaesthetic practitioner (senior nurse and team eader) had arrived in the theatre haf-way through the ist and had missed the team brief at the start. Athough aware that patient number 6 was not ready, she did not expain the change in the running order to the other theatre staff. The operating surgeon then faied to check the patient's wristband, assuming that she had the correct patient. The surgeon addressed Mr Mitcham as patient number 6 when he arrived in theatre, but he did not correct her. It had become norma practice for operating surgeons to identify patients on the ward, at the consent stage, and not to repeat this identity check in theatre. However, patients isted for cataract Queen's Printer and Controer of HMSO 2013. 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. 73

MANAGING CHANGE FOLLOWING EXTREME EVENTS surgery were paced on a generic ist, which meant that the operating surgeon may not have seen a particuar patient before the day of surgery, which is what happened in Mr Mitcham's case. The investigation concuded that the root cause of the incident was a faiure to foow norma checking procedures, which incuded the Word Heath Organization (WHO) theatre checkist. The surgeon was experienced but had been working at Cearview ony since the beginning of that week, and this was her second fu theatre ist. During her induction, guidance on the use of the WHO checkist, and Cearview theatre procedures, had not been cear (hospitas appy this checkist in different ways). The first five patients on the ist that afternoon were operated on without incident. The main recommendation foowing this incident concerned the correct use of the WHO checkist. Induction processes in ophthamoogy were reviewed and the importance of foowing checking and handover procedures was reinforced. As norma, to provide an impartia assessment, the incident investigation was conducted by the hospita's assistant director of risk and patient safety and a patient safety manager. They were advised by a Serious Incident Management Group, which incuded a consutant ophthamoogist, the ophthamoogy unit eader, two operations managers, a divisiona ead nurse, the head of medica staffing and the Patient Advice and Liaison Service (PALS) manager. There had been four never events in Cearview theatres over as many weeks in 2011: a retained camp in a patient's neck foowing surgery, cardiac arrest during sight-saving surgery eading to an adverse neuroogica outcome, a retained fish foowing abdomina surgery and the wrong impant for Mr Mitcham. Foowing a ong period in which no such incidents had occurred, the theatre teams had a high performance high reiabiity reputation and were surprised and shocked that these events had occurred and were concerned that this shoud not happen again. Three members of the research team were thus invited to run a workshop in March 2012 on managing change after extreme events for 11 members of the theatre management group. The workshop aim was to provide fresh perspectives and toos to hep participants deveop soutions. One of these toos concerned the deveopment of mess maps to hep expain why these events occurred. 215 Workshop participants were asked to deveop a mess map for each of the four never events, using fip charts and Post-it notes, identifying immediate causes, aong with the roe of underpinning issues and contributory factors, the externa context, oca conditions and other reasons. 206 The mess map for Mr Mitcham is shown in Figure 7. This echoes the findings of the investigation: new surgeon, inadequate induction, poor communications, ax checking procedures. The mess map aso identifies four other sets of contributory factors, not picked up by the incident investigation: Externa pressures. The map notes the 18-week RTT target and the need for externa reporting of never events, even though in this case no patient was harmed. Interna pressures. The morning cinic was busy, surgeons were under pressure to get a move on, surgeons arrived ate, staff missed their unch break, surgeons had compained that afternoon ists were too ong. Persona preferences. Medica staff behaviour coud be idiosyncratic, everybody does their own thing, the new surgeon had a different ens-matching practice, the consutant was doing paperwork at the time. Smooth running. Paradoxicay, this incident may have occurred in part because things were going we Friday afternoon, experienced staff, mundane process, five cases routine, changing ist order is commonpace; did a successfu theatre team drop their guard under these conditions? This mess map, produced reativey quicky during a workshop by staff who were invoved in the incident, appears to offer a richer expanation for the incident than the carefuy researched investigation report, and refects more cosey the systems-theoretica mode of incident causaity expained earier. 74 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Cataract surgery ist Friday afternoon Experienced nursing staff Staffing OK Busy cinic in the morning Everyone has their own way of doing things Patient six on ist of seven is not ready 18-week RTT target Pressure on surgeons to get a move on Did staff get a unch break? Have to report never events externay: PCT, CQC, monitor Consutant doing paperwork WHO handover checkist carried out Two systems for patient notes: hard copy and EPR Nurses do not te doctor patients six and seven swapped Mundane process Friday afternoon Changing ist order is commonpace WHO team briefing carried out Doctor sees patient independenty of consutant Surgeons arrive ate Anaesthetic practitioner decides to take patient seven to save time Patient seven is brought to theatre with notes WHO advised surgica pause not carried out correcty Surgeons compain PM ists too ong for quaity eye surgery Last case on the ist: six of seven Five cases carried out routine Surgeon seects ens from ist without reference to patient s notes New surgeon, first week in this trust Surgeon unaware of WHO processes New surgeon did not know our way WHO checkist not carried out in fu Loca anaesthetic given; patient s ID not checked Surgeon addresses patient seven as patient six, but gets correct response Surgeon did not have WHO checkist training on induction Sign in and sign out are not competed Surgeon s practice to write ens power on ist beside patient s name Anaesthetic practitioner tes nursing staff patient six swapped with seven Anasthetic practitioner does not te surgeon patients six and seven swapped Patient given wrong ens FIGURE 7 Mess map of the Mr Mitcham never event. EPR, eectronic patient record. Queen's Printer and Controer of HMSO 2013. 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. 75

MANAGING CHANGE FOLLOWING EXTREME EVENTS In the aftermath of future incidents of this kind, one option woud therefore be to compement impartia RCA with a mess mapping process invoving the staff concerned, to deveop action pans to which those staff have themseves contributed. There was further interna support for the concusions of this mess mapping exercise. The trust had formed a Never Events Group, to identify actions to prevent further incidents and to give staff the opportunity to comment on their view of ife in the theatres and any factors which might impact on their abiity to deiver the highest standards of care to our patients. This second aim was achieved through istening events in November 2011, with 10 senior staff acting as faciitators and which invoved over 100 staff, who wecomed this opportunity to share their views. The istening events report categorised the feedback as foows: procedures and systems: not enough time to spend with patients cuture in theatre: buying, racism, spinning out procedures to fi the time communication and team interaction issues: inconsistent and contradictory messages eadership: ack of engagement with staff, watching not experiencing training: non-existent induction processes, peope moving too quicky staffing issues: ack of porters, ratio of trained to untrained staff cut to critica time pressures: many issues ony apparent on morning of operation, WHO checkist equipment and instrumentation: no systematic review of sets, wrong instruments other: incident handing criticised, safety events hed at times when most cannot attend. Despite evidence pointing to organisationa conditions and system properties, the report concuded: It shoud be remembered that the four never events were, to varying degrees, the resut of individuas faiing to foow procedures and good practice. However, if any of the factors identified in the istening events acted as contributory factors then action needs to be taken to address these issues. Individua human faiures were thus seen as the primary expanation for these never events. This concusion makes the fundamenta attribution error of baming individuas and overooking the context in which they work. 216 The concusion aso overooks the trust's own evidence concerning ife in the theatres. A more comprehensive approach to understanding why this incident happened is iustrated in Tabe 33, which ocates the combined findings from the investigation, the theatre team's mess map and the istening exercise in Rasmussen's probem space. 209 Athough thorough induction training and verification processes are important, to reduce the future incidence of never events in theatres this anaysis points to a wider change agenda, addressing organisation, management, staff, infrastructure and process issues (some of which were subsequenty addressed). Viewed from a systemic perspective, it is aso possibe to reach beyond one incident, and consider what can be earned from incidents ike this. Managing change in wicked situations We are good at reporting, we're good at investigating, we're good at making recommendations. But it a fas apart in the impementation. Either things don't get impemented at a, or they get impemented, and if you go back one year, two years, three years ater, it's sowy taied off, to a point where nobody quite knew why we were doing it anyway, and something ese has come aong. Assistant director, Cearview The aim of this sma-n anaysis of four idiosyncratic cases is not to generaise to the popuation of such events, but to inform theory and practice, particuary with regard to the impementation of changes aimed at preventing or reducing the incidence and impact of such events in the future. This invoves a combination of anaytica refinement and naturaistic generaisation. 35,37 The former concerns deveoping understanding of theory, refining current assumptions and concepts, whereas the atter concerns the 76 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 33 Mr Mitcham in Rasmussen's probem space System ayer Government Reguators Organisation Causa and contributory factors 18-week RTT target Need to report never events to externa reguators Cuture in theatre: buying, racism, fiing time Busy morning cinic Non-existent induction processes, peope moving too quicky Staffing, ack of porters, ratio of trained to untrained staff critica Time pressures, not enough time to spend with patients Management Leadership, ack of engagement with staff, watching not experiencing Pressure on surgeons to get a move on Surgeons compain that afternoon ists are too ong Surgeon did not have adequate WHO checkist training on induction Incident handing probems, safety events run when most cannot attend Staff Experienced staff, adequate numbers Everyone has their own way of doing things Consutant doing paperwork Surgeons arrive ate Anaesthetic practitioner takes patient 7 to save time Surgeon seects ens without reference to patient's notes Infrastructure and equipment Two systems for patient notes: hard copy and eectronic record No systematic reviews of surgica sets, wrong instruments Processes and procedures Faiure to foow checking procedures; sign in, sign out not competed WHO-advised fina preoperative pause not conducted correcty Uncear guidance on theatre practice during induction Doctor sees patient independenty of consutant Friday afternoon, mundane process, five cases competed without probems Changing ist order is commonpace Did staff get a unch break? Nurses do not inform doctor of changed running order Patient ID not checked when oca anaesthetic given transference of ideas and soutions to simiar contexts. (A fifth case, a norovirus outbreak at Watte Park in which the incident definition was ambiguous, is described in Appendix 4.) The management of extreme events concerns the inkages between an understanding of why an event happened (causaity), the changes that need to be impemented to defend against a recurrence (agenda) and the impementation of those changes (process). Tabe 34 outines the findings from the four events reported here with regard to those issues and to the outcomes. Managing change in such settings is probematic. In breach of conventiona change management guideines, staff who are to be affected are excuded from contributing to the change agenda, other than as witnesses Queen's Printer and Controer of HMSO 2013. 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. 77

MANAGING CHANGE FOLLOWING EXTREME EVENTS TABLE 34 Causaity, agenda and process Incident Causaity Agenda Process Outcomes Burnside Systemic, mutiayered probem Systemic mutiayered soution Powerfu and enduring team Change successfu and sustained Mayand Systemic, mutiayered probem with ong timeine 46 items for pharmacy, patient care, education and training, medica records and communication Steering group, working groups, changes mandated but not managed New poicy, structures, processes and documentation, but working practices unchanged Torrens Inadequate patient assessment, staff training and patient support Coser coaboration between acute and menta heath trusts Management meetings, difference of views, no project ead responsibe Unresoved, ongoing, minor changes to faciities Mitcham Theatre guideines not foowed (staff identify other issues) Improve induction, use guideines None: dissemination of investigation report Too eary to judge (no further never events to date) giving evidence, and the impementation process is more ikey to be directive than participative. Borrowing the concept of wicked probems, 217 this coud be seen as managing change in wicked situations with the properties outined in Tabe 35. This can become a super wicked situation if: There is more than one organisation invoved and their perspectives differ. This was a repeat of at east one previous incident, so past soutions have not worked. The media picked up the story; they are ooking for a scapegoat and demanding action. TABLE 35 Managing change in wicked situations Causes The trigger event has a compex, mutiayered expanation Immediate causes are combined with atent or underying factors The event timeine reaches deep into the past and can extend ong into the future Some of the basic assumptions of those invoved have been chaenged Stakehoders are arguing about what caused this; some do not think it is a probem Agenda The defensive agenda comes from the recommendations of an investigation Gaps and faws in organisation and management processes have been reveaed There is an expectation of quick fixes, to cose the incident Stakehoders disagree about what changes, if any, are appropriate There is no correct soution, and it cannot be guarantee that the changes wi work Process Change has been deayed pending the investigation The urgency has gone, but other emotions inger disbeief, anger, guit, apathy The norma rues of change impementation do not appy Those who wi impement were excuded from deveoping the agenda Changes to work, organisation and management practices wi be resisted 78 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 None of the events reported here attracted significant media attention. The death of Mr Torrens appears to have created a super wicked situation, given the organisationa tensions invoved. Drawing on the successes and probems arising in those incidents, the management of change in wicked situations may invove deveoping context-sensitive approaches with these properties: Agenda. Go beyond quick fixes and address underying system issues; use this as an opportunity to address ong-standing organisationa probems; deveop a progressive change agenda, inked if necessary to a defensive one; restore the sense of urgency that accompanied the incident in the first pace; receptiveness to change may not be high, and may require stimuation; estabish meaningfu metrics to track progress. Process. Secure ong-term senior management support and resourcing; structure a project team, steering group or board that can act on their decisions; engage coeagues who were excuded by the investigation process; resove competing views of event causaity and appropriate responses; address resistance to the difficut changes to roes and working practices; design a communication strategy that wi inspire as we as inform; aim to sustain changes beyond initia impementation and success. Two environmenta issues may aso be important in some settings. One concerns handing the media reporting the story, who can infuence the change agenda. The other, as in Mr Torrens' case, concerns managing interorganisationa tensions and differences of perspective. In wicked situations such as those found here, it may therefore not be adequate, as some commentators have suggested, 205,213 simpy to provide risk management personne with deveopment in change management capabiities, or to have change management speciaists on investigation teams. Investigation processes are currenty driven by speciay formed, impartia groups, using prescribed tempates, aiming to produce a quaity report, incuding practica recommendations, within a set timescae. What may aso be hepfu, instead of or perhaps in parae with that forma approach, is a process driven by the staff invoved in an incident, using reativey simpe and fexibe mess mapping and other appropriate toos, to identify immediate and systemic changes that wi have a sustainabe impact. Serious incidents, never events and other types of accident and faiure can be regarded as inevitabe features of compex systems. Appropriate responses to this observation thus incude constant scanning for warning signs, deveoping fexibe, context-sensitive working practices and heping those invoved to dea with ambiguity and to make decisions that are often based on uncear and evoving information. Is it possibe to organise in ways that aow probems to be anticipated and caught before they become crises, and to deveop systems for containment as we as for effective responses? These are the goas of researchers and commentators advocating high-reiabiity organisation characteristics. 203,218 Given the compex, systemic, organisation-wide antecedents of these kinds of incidents, it is perhaps not surprising that it has aready been suggested that high-reiabiity concepts can be adapted to heath-care contexts. 219 Originay based on studies of aircraft carriers and nucear power instaations, the quaities of high-reiabiity organisations incude mindfu preoccupation with faiure, reuctance to simpify interpretations, sensitivity to operations, commitment to resiience and deference to expertise. Expertise often resides with front-ine staff who are cose to the fow of events, and more senior staff must be prepared, when appropriate, to reinquish command. Deveoping a high-reiabiity approach requires a sustained organisation-wide programme, rather than managed fixes foowing specific incidents. With the priority attached to improving the quaity and safety of patient care whie reducing costs, the systematic taioring and evauation of high-reiabiity methods in acute heath-care settings woud constitute a vauabe research agenda. Queen's Printer and Controer of HMSO 2013. 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. 79

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Chapter 7 Management contributions Introduction The focus of my roe ies with cinica and manageria strategy and service business pans. The aim is to carify thinking for the future. I work cosey with the medica staff, to bring another set of skis. A ot of my work is commissioned in the corridor. Every service has to deveop a forma vision and strategy, with investment objectives. They are my customers, and I hep them to deveop these pans. With new deveopments, I ask them, what's the story?. Often it's about bringing peope into the room, exporing their positions, and reconciing these. With one of our services, it took a year to get a consensua story; there were big issues on which different peope had different views. So this is a mediating and faciitating roe. Sometimes this even invoves proximity taks when reationships are poor. I'm a quiet spoken pushy bastard. One consutant cas me the spin doctor. I'm good with words, reframing, convincing. I ike getting resuts. It doesn't aways work. Assistant director, Cearview This study sought to deveop a profie of midde management contributions and to understand: how management work affects cinica and organisationa outcomes factors impeding management contributions to performance how an enabing environment for management work can be assembed and sustained. This chapter first reviews past research concerning midde management contributions in genera and in heath care, before exporing the combined evidence from this project. The main concusions are: Previous research shows midde managers in genera contributing to organisation strategy and performance, through mediating, boundary spanning, innovating, championing, infuencing and change impementation roes. Past research offers a simiar account of midde managers in heath care, with human resource, operationa and performance management practices being inked to improved patient outcomes and organisationa performance. From this study, the profie of midde management contributions incudes maintaining day-to-day performance, firefighting, ensuring a focus on the patient experience, identifying and seing new ideas, transating ideas into working initiatives, process and pathway redesign, faciitating change, troubeshooting, everaging targets to improve performance, deveoping infrastructure, deveoping others and managing externa partnerships. Past research indicates that supportive cutures combine fexibe roes and structures, freedom to innovate, resources and senior management support. Conditions that constrain midde managers incude systems and poicies that encourage conservative behaviour, compex approva cyces, micromanagement, ack of autonomy and uncear direction from the top. The components of an enabing environment for management work incude top team communications, business inteigence, cutting non-vaue-adding activity, autonomy to innovate, organisation structures, organisationa norms, performance management, interprofessiona work, support services, persona deveopment, teamwork and resources; investment in information systems, management deveopment and additiona resources can be costy, but action to improve the enabing environment under other headings is cost neutra. Evidence from this study aso indicates that encouraging co-management shared eadership of change by cinica and manageria staff working coaborativey coud have major benefits for cinica and organisationa outcomes. Severa other ow-cost, ow-risk, high-impact suggestions for buiding an enabing environment were generated. At a time of rising demand and diminishing resources, it is not cear why these were not more common in practice. Queen's Printer and Controer of HMSO 2013. 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. 81

MANAGEMENT CONTRIBUTIONS The strategic midde manager Managers make a huge contribution to patient care, deveoping services, measuring quaity. One of the key things that I find mysef doing is drawing ideas together and impementing them. I go to a the cinica meetings, and I'm heaviy invoved. I aso attend consutants' meetings. I act as a inchpin. If I'm not there, the discussion and outcomes can become more fragmented. Genera manager, South Netey Midde managers at arge There is research evidence to support the negative stereotype of midde managers, regardess of sector. Nationa poitica and media commentary during this project aso pictured heath-care managers whose main contributions to the service incuded bureaucracy and overheads (see Chapter 3). From an anaysis of the interventions of 90 midde managers in the decision processes of their firms, Guth and MacMian 220 concuded that those who fet that their sef-interest was compromised coud sabotage, deay or damage the impementation of strategic initiatives. Meyer 221 showed how midde managers subverted a merger process that was not in their interests. Emphasising the roe of persona goas, Siince and Mueer 222 note that midde managers reframe directives and tak down expectations when strategy is seen to be faiing, and when they are ikey to be bamed. However, the weight of research indicates that these findings do not generaise to the management popuation as a whoe, and evidence from this project indicates that the negative portraya of midde managers in heath care is inaccurate. Bower 223 was one of the first to recognise the importance of midde managers as change agents, with upwards infuence on strategy based on knowedge of the organisationa context, nurturing, testing and championing initiatives and contributing fexibiity by deviating from forma expectations. From her study of 165 midde managers, Kanter 224 concuded that a company's productivity depends to a great degree on how innovative its midde managers are (p. 95). Context, however, is important. Kanter found innovation fourishing in companies in which territories overapped, with frequent cross-functiona contact, free fows of information and excess in budgets, and in which many managers had oosey defined roes and assignments ( sove probems ). Mutipe reporting reationships and overapping territories, Kanter argues, encourage managers to deveop their own ideas and se them to their peers. Midde managers' contributions to innovation and change are widey recognised, party because of the work of Woodridge and Foyd 225 who argued that midde management invovement in shaping strategy ed to better decisions, higher degrees of consensus, improved impementation and better organisationa performance. They deveoped a typoogy of midde management contributions to strategy: (1) gathering and synthesising information, (2) justifying and championing aternatives, (3) faciitating organisationa adaptabiity (reaxing rues, buying time ) and (4) transating goas into action and seing initiatives to staff. 12,29,226 They aso emphasise the co-ordinating, mediating, interpreting and negotiating roes of midde managers, arguing that it is difficut to isoate an individua's roe because it is the pattern of strategic infuence of midde managers that affects performance. The boundary spanners are more infuentia, and senior managers wishing midde managers to be more innovative are advised to consider putting more managers into reguar contact with the environment (p. 482). 226 Research continues to emphasise midde managers' roes in shaping, mediating and impementing strategic change. 58,227 Boyett and Currie 228 report how midde managers in an Irish teecommunications firm designed an aternative strategy that was more profitabe than the one that senior management had intended. Mair 229 aso argues that midde managers can infuence organisationa performance through the way in which strategy is enacted. She found that superior unit performance in a financia services firm was associated with midde managers whose actions were aigned with corporate strategy. She aso found that midde managers with many roe moves performed better than those who stayed put (experiencing no new chaenges). 82 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Managers may not aways be free to exercise these strategic roes. Kuratko and Godsby 230 identify conditions that discourage the entrepreneuria midde manager from taking risks and innovating: systems and poicies that encourage consistent, safe, conservative behaviour compex approva cyces with eaborate documentation contros that encourage micromanagement top-down management and ack of deegated authority. Midde managers combine access to top management with knowedge of operationa capabiities. Woodridge et a. 30 concude that a midde management perspective is vauabe, party due to that mediating roe, and as a counter to the upper echeons view of strategic choice. They aso note that compex geographicay dispersed organisations cannot be managed by singe actors or even sma groups but require distributed and interactive eadership throughout the organisation, with midde managers as important mediators between eves and units (p. 1191). Baogun 231 argues that, even when midde managers are change recipients, the way in which directives are interpreted and impemented may differ from (and improve on) senior management intentions. Midde managers in heath care Previous research has found midde managers paying simiar strategic roes in heath care. The impact of management practices on patient outcomes is iustrated by West et a. 23 Their survey of 61 Engish hospitas found that mortaity rates foowing emergency and eective surgery were significanty ower in hospitas with human resource practices concerning staff appraisa, training and teamwork. This reationship was stronger when the human resource director was a fu voting member of the hospita management board. Suspicious of those resuts, medica staff asked how management practices coud affect patient mortaity. The researchers' response 232 was: Our answer is simpe, though it may seem strange to those who dea with individuas rather than organisations. If you have HR practices that focus on effort and ski; deveop peope's skis; encourage co-operation, coaboration, innovation and synergy in teams for most, if not a, empoyees, the whoe system functions and performs better. If the receptionists, porters, anciary staff, secretaries, nurses, managers and, yes, the doctors are working effectivey, the system as a whoe wi function effectivey. p. 35 22 A study in the Heath Service Journa found that trusts rated weak on service quaity in 2009 had increased midde management numbers by ony 5% between 2004 and 2008; trusts rated exceent, in contrast, had increased management numbers by 46%. 233 This impies that weak trusts were undermanaged and that cutting management coud adversey affect service quaity. From their survey of 50 senior NHS managers, Hutton and Caow 234 observe that the service is sow to adopt new ideas because of rigid structures, poor communication channes, inadequate decision processes and ack of knowedge management skis. Even when a new approach is agreed, impementation can be poor, and manageria intervention, they argue, is essentia to drive innovation to improve quaity, productivity and safety. Management practices in genera, and human resource practices in particuar, affect individua, team and organisationa performance. High-performance human resource practices affect work design, training and deveopment, performance appraisa, teamwork, invovement, autonomy, and eadership stye, with the aim of improving ski, motivation and commitment and thus performance outcomes. 235,236 Dorgan et a. 25 deveoped an assessment covering three sets of practices: operationa management, performance and targets management and taent management. First appied to manufacturing and retai organisations, 237 this was used to compare management practices in 1200 acute hospitas in seven countries, incuding Queen's Printer and Controer of HMSO 2013. 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. 83

MANAGEMENT CONTRIBUTIONS 184 hospitas in the UK. Hospitas were given a management score (1= weak, 5= strong ) that coud then be compared with performance measures. To score 5 for taent management, hospitas have to operate systems for managing high and poor performers, training and deveopment, recruitment and retention. A top score for operations management is based on ayout and patient fows, pathway management, standardisation of cinica processes and protocos and effective use of staff. The top score for performance management considers how process improvements are addressed, how quaity indicators are used for performance tracking, conduct of performance reviews and consequences when agreed pans are not enacted. Five sets of factors were found to infuence management practice scores: 1. competition: hospitas facing more competition had higher scores than those facing itte or none 2. skis: hospitas with cinicay quaified senior managers had higher scores, presumaby because those managers were better abe to communicate with cinica staff (the UK had the owest proportion of cinica managers, 56%, compared with 93% in Sweden) 3. autonomy: hospitas that gave managers higher eves of autonomy scored more highy 4. scae: arger hospitas had higher management scores than smaer units 5. ownership: private hospitas scored more highy than pubic hospitas. Carefu not to caim causaity, the researchers suggest that these findings confirm that management reay does contribute to patient we-being a caim supported by the observation 25 that, in the UK, a 1-point increase in management practice score was associated with: a 6.5% reduction in death rates for emergency patients with heart attacks (30-day risk-adjusted acute myocardia infarction mortaity rate) a 33% increase in income per bed a 20% increase in probabiity that a hospita is above average for patient satisfaction. From their anaysis of NHS staff survey data from 2006 to 2009, West et a. 238 concude that management practices that offer a positive experience for staff ead to positive outcomes for staff and patients, infuencing patient satisfaction, mortaity, infection rates, absenteeism and turnover (NHS staff are absent, on average, 10.7 days a year, costing 1.75B). Factors that increase engagement incude good management and eadership, a safe work environment, meaningfu roes, support for persona deveopment and invovement in decision-making. Echoing the previous study by West et a., 239 one predictor of patient mortaity rates was the percentage of staff working in we-structured teams with cear objectives, meeting reguary to review and improve performance. The notion that heath-care managers contribute ony to red tape and costs appears to be inaccurate. Midde managers mediate between the front ine and the top team, shaping and championing innovations, infuencing others to support change and impementing service improvements. High-performance practices are associated with staff engagement, patient satisfaction, mortaity rates and other positive cinica outcomes. One study even showed that trusts that had achieved better service quaity ratings had increased management numbers. Evidence from this study This section first expores the pressures and demands on midde management and then considers contributions to cinica and organisationa outcomes. Pressures and demands Drawing on survey evidence, Chapter 5 expored the pressures and demands facing midde managers. A simiar picture emerged from content anaysis of set-up interviews, refecting the mutioaded nature of 84 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 the management agenda and the ways in which midde management roes are changing. These pressures are revisited in brief here. The pattern of themes was broady simiar across a six trusts, except for oca issues such as the merger at Watte Park, reocation at South Netey and serious incidents at Netherby. The main pressures and demands on midde management incuded: finance: pressure to cut costs, an increasingy compex funding mode workoad: increasing, no headspace, need broad shouders and thick skin reguation: burdensome bureaucracy, daiy pressure to meet targets systems: dated IT system, inadequate information, fighting with systems that do not work externa reations: overcoming boundaries, acute and primary care not joined up change: no resources to impement new ideas, change is extremey sow staffing: staff shortages and recruitment probems, insecurity, fatigue other: pubic expectations, taking patients seriousy, earning from serious incidents. Rising pubic expectations, increasing workoads, financia chaenges, burdensome reguation (externa and interna), staffing probems, poor information systems, the difficuties of impementing change, and reationships with externa agencies such as commissioning bodies were common themes. Once contributions have been expored, we wi turn to participants' suggestions with regard to deaing with those pressures and to deveoping an enabing environment for management work. Management contributions This study focused on midde management contributions to cinica outcomes and to organisationa performance in genera. These contributions are mutifaceted, and evidence has been drawn together from severa sources, forma and informa, incuding access meetings with senior hospita staff, interviews, focus groups and feedback from participants during project update and briefing meetings. Tabe 36 summarises the contributions profie deveoped from that evidence. TABLE 36 Management contributions to cinica and organisationa outcomes Contribution Maintaining day-to-day performance Firefighting Patient experience focus Identifying and seing Transating ideas into working initiatives Process and pathway redesign Faciitating change Troubeshooting Leveraging targets to improve performance Deveoping infrastructure Deveoping others Managing externa partnerships Expanation Keeping the show on the road, risk assessment, staffing/workforce/human resource management issues, oversight of inks with other headings Listening, probem spotting, rapid response Ensuring that patients' voices are heard when business decisions are being made Spotting, designing and impementing service improvement initiatives, persuading others, working across interna boundaries Shaping ideas from coeagues and externa sources Lean methods, productive ward initiatives Taking risks, working with cinicians, running rapid improvement events Deaing with underperforming areas, finding and deivering cost savings, soving wicked probems Dashboards, benchmarking IT, equipment, physica faciities Skis deveopment, getting peope on board, picking up devoved human resource issues Working with oca authorities, poice, PCTs Queen's Printer and Controer of HMSO 2013. 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. 85

MANAGEMENT CONTRIBUTIONS This profie was initiay derived from content anaysis of set-up interviews in which respondents were asked to cite exampes that iustrate the roe that midde managers have payed in this trust to improve cinica outcomes and quaity of care. This was one question in a 1-hour interview schedue and response patterns varied. Most participants cited a sma number of recent exampes with which they were famiiar. Tabe 35 is thus based on aggregated responses, producing a stereotypica profie. Athough portraying midde management contributions in genera, this profie wi ceary not be consistent with the activities of any one individua or group, and patterns of contributions wi vary over time and with setting and circumstances. To expain how this profie was constructed, Tabe 37 provides a seective summary of the content anaysis of responses of 17 managers at Netherby (four board members, seven hybrids and six managers) who generated 34 exampes of management contributions in five categories. Tabe 38 summarises the anaysis of responses from 13 managers at Greenhi (two board members, five hybrids and six managers) who generated 21 exampes in four categories. Two dimensions of the management contribution that did not arise directy from forma interviews and focus groups concerned maintaining day-to-day performance and firefighting. Focusing on specific exampes, interview answers overooked what might appear to be the more mundane aspects of the management roe. During a project update event, the medica director from Burnside observed that managers' contributions to operationa management were missing: deaing with staff absence, handing devoved human resource management issues, managing beds and patient fows, ocating ost records, acquiring missing equipment, handing compaints, fixing budget probems. The project focus on big and dramatic overooked the routine but no ess important roes that midde managers pay. Aso, discussing how extreme jobs focus attention on immediate probems at the expense of system changes, an operations manager at Cearview defended the firefighting aspect of her roe. She observed that many of the routine probems that arose coud have TABLE 37 Management contributions at Netherby (seective) Contribution Item count Iustrative quotes Process redesign 13 ean methods in pathoogy to take waste out of the system and save time process mapping to become more effective with ess resources new heart centre with redesigned process, reduced waiting time and patient visits and increased capacity Deveoping infrastructure 9 making sure a doctors and nurses have wireess LAN access midde management impemented our digita X-ray system faciities worked with oncoogy to insta the new inac machine a Transating and impementing ideas 5 managers saw business opportunity for new ophthamoogy treatments and deveoped proposas to enabe cinica staff to reaise this managers contribute to soving cinica governance probems managers make the business case for funding Deveoping others 4 deiver nurse practice deveopment training in standard work practices training a staff in bood handing across the patient pathway Leveraging targets to improve performance 3 management benchmarking against other trusts has ed to new working practices and governance arrangements targets for infection contro have sharpy reduced MRSA and C. diff LAN, oca area network; MRSA, methiciin-resistant Staphyococcus aureus. a Linear acceerator, a device that uses high-energy X-rays to treat cancer patients; it costs around 1.5 3M, excuding instaation and running costs. 86 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 38 Management contributions at Greenhi (seective) Contribution Item count Iustrative quotes Faciitating change 14 running corporate rapid improvement events, get whoe departments invoved in reengineering importing new ideas from outside and pioting working with cinicians to impement changes Process redesign 5 process redesign of emergency patient pathway impementation of revised discharge procedures midwifery managers deveoped a new triage system for maternity care Deveoping others 1 bring eadership and deveopment into the organisation to act as a driver for a change of cuture Transating and impementing ideas 1 heping cinica staff with good ideas to transate, shape and impement them adverse consequences for patients if not resoved quicky, and that cinica staff were not aways aware of those issues, nor woud they have the time or the capabiity to dea with them. One respondent at Cearview highighted the work of their Patient Experience Support Team (PEST), which had attracted nationa interest as we as oca support for its work in ensuring that patients' voices were represented when business decisions were being taken: We take our survey data and compaint data, and a senior team incuding the assistant director of nursing and my director ook at it and decide where we are going to go. This period, our department of medicine for the edery had an increase in compaints. Rather than go in and do one ward, we are going in to do a whoe department; twenty-two sessions with 108 staff over a two-week period, based on the probems that they are having. Sometimes you forget that you are traibazing, but we probaby are, it says a ot about the organisation that you are aowed to, you are enabed to go off and do some of this stuff differenty. You don't aways know it when you are doing it that it is so different. I was asked to present at a conference a coupe of months ago. My first event where peope had actuay paid to come and isten to me and the response was just overwheming, peope saying oh my god this is what we want to do. You just don't reaise. For you it is just everyday. You know that some things have worked we and other things not so we, but you don't reaise just how ahead of the game you are. It is good to do that. When I came back I was enthused and wanted to keep it going. Assistant director, Cearview The same respondent at Cearview gave an exampe of troubeshooting in an underperforming area: The emergency department had a high voume of compaints. So we ifted about fifty harsh quotes and ran a day on the quotes; the group owned it competey, and chaenged each other, worried about their reputation. The quarter foowing the training, they didn't have a singe compaint. It hasn't been entirey maintained but it has improved. Assistant director, Cearview Another Cearview respondent cited this exampe of process redesign: We have so many project-based exampes using ean toos. Our recovery team, for exampe, wanted to redesign the area around the bedspace, make it more streamined, easier to cean, to get the team around the patient. They then moved on to the canteen area. We have many of these hundreds Queen's Printer and Controer of HMSO 2013. 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. 87

MANAGEMENT CONTRIBUTIONS of sma exampes. We've aso done a ot of cinica pathway work, for exampe coordination of the paediatric pathway. Can we measure the impact? It's not hard to measure quaity I fee better, and the patients are happy. Senior manager, Cearview Severa interviewees described successfu cinica manageria coaborations, a theme that aso arose in focus group discussions. One (who said that being caed a midde manager is incrediby degrading ) described the foowing initiative: Creation of the emergency assessment unit, which encompasses A&E [accident and emergency]. Typicay in A&E you go get triaged. If you are sick, you get admitted and get seen by a consutant, tweve, twenty-four, thirty-six hours ater. Do we see and treat and send home, or admit then decide what to do with them? We brought the senior consutant review [of each patient] into the first four hours. A chaenging, revoutionary idea, buggers up the four hour target, but is much better ong term; diagnostics are done much faster. Two peope drove that forward, one cinician, and one manager. The two working together was reay important. Neither coud have done it without the other. Assistant director, Cearview The foowing manager gave this exampe of co-ordinating externa partnerships to impement changes suggested by a doctor: One of my successes, which I'm peased about, concerned a doctor in the accident and emergency department who wanted to introduce an initiative to reduce the incidence of acoho-reated crime. This contributes to between five and ten hospita deaths per annum. It was a good idea, but he coudn't make it happen. We, I made it happen. This invoved bringing together the hospita, the oca authority, and poice, getting senior staff interested. We organised a arge conference in a oca cub with about eighty peope. A agencies were represented at senior eve we had the top brass, bouncers, the trust chair. We had to be buish with the poice, but we deveoped an action pan, and those agencies now a meet reguary every month to work through the pan and its impementation. We had a reca conference ast week to review progress, and to draft a pan for next year. The eve of these incidents is down 7 per cent. Assistant director, Cearview This genera manager at South Netey offered two exampes of contributions to patient care quaity in circumstances in which cinica staff either woud not have attempted to sove the probem or woud not have been abe to dea with it on their own: Ambuance deays. Shift coordinators in accident and emergency focus on the patients in the department. They don't see the queues outside. They are not their patients. Deays of an hour were being toerated. So the assistant genera manager [AGM] worked with the shift coordinators and the matron to convince them that this mattered. The consutants are sti binkered in this regard. The AGM got one shift coordinator to ead on this, and to find ways to unoad patients more quicky. We now have fewer patients waiting for transfer from ambuance to emergency department. This has mutipe benefits. They are in a more congenia and safe environment, with better faciities and staff shoud things go wrong. And the ambuance and crew are free to return to duties. Length of stay in care for the edery. Benchmarking showed that any HRG [Heathcare Resource Group] with compex edery in the name was probematic; chest pain with or without compications, over or under seventy-five, and so on. We have a ot with urinary infections. Our turnaround averages eighteen days, whie other hospitas are five or six days. We have discussed what needs to change with the cinicians. This is work in progress, and we haven't got there yet. One suggestion is that a consutant and speciaty nurse review each patient on day of admission. Currenty, this initiative has a ower priority. If I can shift that, I wi be we peased. Genera manager, South Netey 88 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Finay, another respondent at South Netey described the management roe in bringing cinica and other stakehoders together to work coaborativey on an infection contro probem: Another exampe is in infection contro and how we have handed this. The infection contro team reports to the director of nursing. The recenty appointed deputy director of nursing is an individua who can pu things together. Previousy, the infection contro team was disparate, poory managed and poory ed. So we had poor infection contro. The new deputy has given them direction and engaged everybody, and this has made a huge difference to infection contro. She's not the DIPC [Director of Infection Prevention and Contro]; that used to be a microbioogist, who faied to do that (and is now on maternity eave). Our new medica director is the DIPC. The new deputy director got everyone invoved; doctors, nurses, nurses chaenging doctors, she got the faciities peope invoved. Our rates of MRSA [methiciin-resistant Staphyococcus aureus] and C. diff are now very ow. Genera manager, South Netey Midde managers were making a major impact on quaity of care, cinica outcomes and organisationa performance, and taking pride in the resuts. Many of these service improvements invoved issues that cinica staff were unabe or unwiing to address by themseves. Coaborative working, combining different perspectives on probems, was often cited as making a difference. This evidence compements accounts of strategic/entrepreneuria midde managers, demonstrating the wider-ranging contributions to operations management, firefighting and probem-soving, maintaining patient focus, managing externa reationships, improving infrastructure (IT, equipment, estate) and initiating and impementing process, pathway and other changes. This profie was constructed in a context of increasing demands and diminishing resources, with many managers observing that they acked the time, autonomy, resources and top management support to deveop further ideas. This supports the case for reeasing time to manage, aowing midde managers to make an even greater impact on the design, running and quaity of the service. Sweat the sma stuff During this project, the management emphasis understandaby ay with arge-scae changes to the organisation, deivery, funding and reguation of the service. In this context, soving minor, annoying probems woud appear to be unimportant. However, interviews with consutants at Cearview reveaed not ony their support for management, but aso their frustration with minor probems that were not being addressed. This ed to the design of an initiative, sweat the sma stuff, which asked staff in the gastroenteroogy service to nominate minor probems, which were then rapidy soved by a sma project team at minima cost within 5 days, generating benefits for patients, staff and hospita performance. These outcomes strengthened cinica manageria reationships, which are key to impementing arger-scae changes, and which had suffered because the sma stuff was not being fixed. This project won an innovation award at Cearview and was appied in other services. The conference paper reporting this initiative is provided in Appendix 7. Wicked probems Two management contributions troubeshooting and firefighting concern probem-soving. Management probems can be categorised as either tame or wicked. Tame probems are we defined with cear stopping points, soutions can be objectivey seen as right or wrong and possibe soutions can be tried and abandoned. Wicked probems have no definitive probem statement as different stakehoders have conficting views. They have no stopping point; the search for better soutions continues. There are no correct answers, ony better or worse soutions, and wicked probems tend to be unique, without precedents. Learning by tria and error is hard because every attempt counts. 217 Probems become super wicked when time is short, there is no centra authority and those who are trying to sove the probem are aso creating it. Many of the probems that midde managers in acute settings have to dea with are wicked or super wicked probems. Exampes incude organisation cuture change, deveoping service-ine management structures, compex patient discharge procedures and staff performance management. Wicked probems cannot be addressed with ogica, reductionist anayses with which cinica staff are famiiar. The Queen's Printer and Controer of HMSO 2013. 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. 89

MANAGEMENT CONTRIBUTIONS combination of manageria and cinica perspectives can thus be key to addressing these probems. This project experimented with visua toos such as mess mapping. 215 Wicked probems represent a further dimension of the management contribution, finding soutions by combining stakehoder views. What has to change? Interviewer: Red tape, not aowed to use your experience, not trusted to manage I thought the trust was deveoping a cuture that encouraged engagement and empowerment? Respondent: We it's the usua kind of confict between the two. Poiticay correct, and good management processes, encouraging empowerment, engagement, and so on. But, when money is tight, you start getting micro-managed. So things ike duty rosters I can't trust my ward managers now, my ward sisters, to do a duty roster. It's got to come from me, and I've got to sign it off. Because I'm tod that I must sign off rotas. Lead nurse, Greenhi As organisationa probems mount, and new ideas and rapid soutions are at a premium, the senior management refex is often to centraise decisions, to tighten contros, to imit autonomy. As an associate director at Greenhi observed, We need to et go, and that's incrediby difficut at a time when we fee the need to tighten the reins. However, those responses stife innovation and demotivate those who are cose to the probems but who are constrained in the actions they can take. In this disabing setting, midde managers in this study were asked how their contributions to cinica and organisationa outcomes coud be strengthened. There was no shortage of answers. This section summarises those answers and outines a mode of the enabing environment (Tabe 39). Most actions to support an enabing environment for management work are cost neutra. Ony three of these dimensions are cost generating: business inteigence, persona deveopment and resources. To represent the richness of the evidence, we wi first summarise the content anayses of interview responses from two trusts and then present typica responses from focus group discussions. Suggestions for TABLE 39 Strengthening the management contribution: properties of an enabing environment Properties In practice... Top team communications Business inteigence Zero non-vaue adding Autonomy to innovate Organisation structures Organisationa norms Performance management Interprofessiona work Support services Persona deveopment Teamwork Resources Cear, consistent, two way, istening IT systems that provide appropriate and timey information, easiy Streamined governance, simpified audit and compiance systems Fixing probems on own initiative without sign-off deays No sios, information-sharing, cross-service coaboration Patients not targets, engagement, management vaued, risk-taking Hod managers to account, provide support for performance probems Mutua respect between cinica and manageria staff Rapid, appropriate advice, action and probem-soving Leadership and management training and deveopment Coaboration, information-sharing, consider wider impact of decisions Staffing, investing to save, granting decision rights within budget 90 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 strengthening management contributions dispayed simiar patterns irrespective of trust or respondents' roes. So, for exampe, content anaysis of responses from 17 interviewees at Netherby generated 45 ideas, highighting suggestions for appropriate action. Most suggestions concerned top team communications, autonomy to innovate, organisationa norms and performance management. Tabe 40 shows an iustrative seection. The 12 interviewees at Greenhi generated 56 ideas. Simiar to the Netherby responses, this pattern is iustrated in Tabe 41, again emphasising the importance of top team communications, autonomy to innovate, organisation norms, performance management, organisation structure, persona deveopment and adequate resources. Focus group participants were asked the same question: what woud have to change in order to strengthen the contributions that you as a manager can make to quaity of patient care, and to cinica and organisationa outcomes? The pattern of responses was consistent with those from interviews. Here are just three exampes from the 40 focus groups that were conducted during this project. One focus group at South Netey incuded matron neurosciences, assistant genera manager medicine, quaity manager, human resources partner, assistant genera manager, physiotherapy team ead trauma TABLE 40 Strengthening the management contribution at Netherby Theme Top team communications Suggestions and areas for attention (seective) stabiity and direction from top team pease senior managers not istening to midde and front ine executive team shoud be more incusive, isten to front-ine managers Business inteigence rea-time information that identifies the hot spots we need to infuence better information systems technoogy to expoit rea-time information Autonomy to innovate et's not have a decisions made on the executive directors' corridor empower midde and front-ine managers to make decisions shape the service without having to jump through hoops and be knocked back Organisation norms baance the pressure on targets with focus on quaity of patient care we don't stea ideas from others often enough address the manageria medica sios and mindsets Performance management provide support to tacke performance management issues we reward bad practice by giving additiona resources you don't need to do much to be seen as doing a good job Interprofessiona work too much time devoted to interprofessiona power and status strugges training for doctors and nurses funded differenty perpetuates barriers Support services provide support, don't dampen enthusiasm good, consistent HR support Persona deveopment management deveopment processes aow managers to go visit other paces, do research, tria things Resources enough money to make things happen HR, human resources. Queen's Printer and Controer of HMSO 2013. 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. 91

MANAGEMENT CONTRIBUTIONS TABLE 41 Strengthening the management contribution at Greenhi Theme Top team communications Business inteigence Zero non-vaue adding Autonomy to innovate Organisation structures Organisation norms Performance management Interprofessiona work Support services Persona deveopment Teamwork Resources Suggestions and areas for attention (seective) do directors know what it's ike to work on an understaffed ward? change the IT genera managers doing administration, burdened with dross aow midde managers to think about and deveop ideas divisiona structure is divisive traditiona professiona sios we do fixes and patches we need to rethink, ook outwards we have no performance management, hod peope to account few consutants comfortabe with mutiprofessiona programmes what can we do to support those in increasingy chaenging roes? eadership deveopment for a management roe, there is no training use the skis and knowedge and innovation we have in teams peope are on their knees inspirationa peope who are weary and orthopaedics, neurosciences physiotherapy team ead, assistant genera manager surgica services, advanced nurse practitioner neuroscience, physiotherapy manager and eadership deveopment consutant. From a ong ist of ideas for strengthening their contributions, their priority areas were: carity and priority around goas; cear strategic direction senior management speak transformationa then act transactiona give us space to achieve; freedom to try things out, without the bureaucracy carifying expectations for ward staff, particuary responsibiities of band 5 nurses norms and cuture get in the way, but we know these are hard to change performance management the NHS is not accustomed to this so when peope don't deiver, there is itte or no accountabiity; but performance management can be supportive human resource poicies for proper sickness, absenteeism and performance management need to deveop coping strategies, surviva skis. Once again, top team communication, autonomy to innovate, organisation norms, performance management and persona deveopment were significant. This focus group aso suggested more information, fewer rumours, ess whizzing around operationay, change in cuture away from command and contro and ess strugging to understand the anaytica information we're given. They aso suggested that senior management come and work with us, to understand what's going on, and wanted to see the executive team modeing the behaviour that we are expected to demonstrate (they were no onger aowed to use bank staff whereas the executive team hired externa management consutants). Reinforcing earier discussion of cinica manageria coaboration, this focus group aso expressed the desire for an increased cuture of cinica manageria joint working. A second exampe concerns a focus group with four modern matrons at Greenhi who identified the suggestions in Figure 8, indicating what they fet there shoud be more of and ess of. Supporting the fina comment in Figure 8, a ward sister in another Greenhi focus group said: I tacked the CEO in the meeting and got nothing. I e-maied him, and I got a wishy-washy response. And when I chaenged him on the issue he was rude to me. Communication from the top down has to improve. It's amost as if they have a hidden agenda. 92 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Our third focus group exampe concerns the 10-member operations management team in the medicine division at Cearview, incuding operations managers, deputy operations managers, division support managers, divisiona ead nurse and senior cinica nurses. Their suggestions for strengthening the management contribution covered individua, divisiona and corporate actions. At an individua eve, time management, deveoping sef and others, being in the know, roe carity and being more proactive and risk-taking were seen as important actions: I get invoved in the nitty gritty, I shoud not have to, more time with ine manager to emuate skis, keep up with new programmes, be aware, review job roes and tasks and how they need to change and move from being reactive to proactive and take more risks, more power to act with patients, use judgement. At a divisiona eve, being in the know was again important, aong with meetings management, roe carity, earning and sharing practice, and human resource poicies: we shoud a take responsibiity to stay informed, ensure that groups, forums, workstreams have consistent attendance from the same peope, not different peope each time, which reduces engagement, cear roes and responsibiities; understanding of roes of others, earn from the firefighting incidents, and share best practice more across the division and enabe staff to do the job and tighten up human resources processes. Corporate actions recommended by this focus group incuded improved centra human resource support for recruitment, more opportunities for forma and informa networking with peers, better communications between divisions, better carity of roes, the ceebration of errors as earning opportunities rather than Less nagging and negatives More thanks and positives They re constanty nagging at us. My genera manager is ike the grim reaper. No positives, a negatives. We never get any thanks or positives, even when we have made our targets. Less bocking of initiative More abiity and scope to impement and to faciitate change Impementing anything new takes massive amounts of energy, and you are ground down. You get doors cosed in your face repeatedy. More support from support services: estates, human resources, occupationa heath Simpify unwiedy processes More encouragement for innovation Better communications to and from board members Communications with the chief executive and the board. They don t tak to us. We re mushrooms. FIGURE 8 What has to change: modern matrons at Greenhi. Queen's Printer and Controer of HMSO 2013. 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. 93

MANAGEMENT CONTRIBUTIONS a bame cuture, support services with a customer orientation, dissemination of best practice a earning and sharing organisation stronger trust vaues with regard to respect for and engagement of staff, and reduced confict between finance and patient safety. It is significant to note that these ideas concern aspects of persona stye, approach to the job, time aocation, the carity with which roes are defined and understood, responsibiities, communications, sharing, earning, support, networking, vaues. None of these suggestions impy the need for additiona resources. Other than the potentia opportunity costs invoved in acting differenty, these suggestions for strengthening management contributions woud be free to impement, and woud have potentiay significant positive impications for cinica and organisationa outcomes. Space imitations do not aow a fu reporting of the responses from a 40 focus groups, which raised simiar themes and issues. Shown against the same 12 themes, Tabe 42 ists the 24 ways to strengthen the management contribution codes from the combined focus group content anaysis. Transating this information from interviews and focus groups into guideines for management practice, corporate issues that appear to be of particuar significance and concern incude: TABLE 42 Strengthening the management contribution: focus group issues Theme Top team communications Focus group content anaysis codes Better eadership, panning and stabiity Carity of strategy Better support and eadership from senior managers Improve communication and recognition Business inteigence Zero non-vaue adding Measures, metrics and data Reduce targets and bureaucracy Standardisation of processes Autonomy to innovate Increase authority, ownership and accountabiity Focus on change management and new ideas Organisation structures Organisation norms Change structure, systems and processes Cuture/cimate Increased patient and cinica focus More earning from others and improved inks Focus on outputs and achievements Become more businessike Performance management Interprofessiona work Support services Improved performance management Reationships with doctors Better seection of staff Improved support systems Persona deveopment Training and deveopment Deveop resiience, manage expectations Teamwork Resources Teamwork mentaity and staff engagement More staff More time and space 94 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 carity and consistency with regard to trust goas and priorities cear and consistent communications that keep staff we informed support services with a customer orientation providing effective and timey support updated IT systems that provide appropriate financia and other management information strengthened performance management systems investment in eadership and management deveopment encouragement and support for cinica manageria coaboration. Board-eve executives may in addition wish to consider: not interfering in operations; focus instead on panning and prioritising avoiding a panic of the week approach istening to midde managers who have a better understanding of operationa issues invoving midde managers in key decisions empowering midde managers to make decisions, giving them space to achieve emphasising positives rather than negatives. Steps that individua managers said that they found usefu incuded get out and about, make time for refection, ook at what processes and practices coud be done differenty to reduce the pressure, avoid perfectionism, find support in coeagues and deveop persistence, poitica ski and a thick skin. In sum, be more proactive, refective, sef-aware and resiient. A contributions-based mode of management This study aimed to deveop a profie of midde management contributions, to understand how cinica and organisationa outcomes are affected, to identify factors impeding management contributions and to estabish the dimensions of an enabing environment for management work. In this fied, one research tradition focuses on management roes and activities. A second tradition concentrates on inking aspects of management work to organisationa outcomes. In other words, an interest in what managers do sits aongside a focus on what managers achieve the added vaue. This study aimed to contribute in particuar to the atter tradition, not by attempting to correate specific management practices with performance metrics, but by profiing the contributions of the midde management function, and demonstrating how these are shaped by institutiona and organisationa contexts. Figure 9 summarises the overa argument of this project, drawing as indicated on the concusions of previous chapters. This is oosey based on the mode deveoped by Woodridge et a. 30 Their organising framework is designed to inform research rather than to expain how the management contribution is enabed and constrained, and indicates the significance of institutiona and organisationa contexts without detaiing their properties. Figure 9 in contrast shows how midde management contributions in heath care are shaped by nationa institutiona and oca organisationa contexts, by the composition of the management function and by the enabing (or disabing) properties of the environment in which midde managers operate. Previous cross-sector research portrays midde managers contributing to organisationa outcomes through infuencing strategy, by nurturing and championing initiatives and through co-ordinating, mediating, interpreting and negotiating roes. The advantages that midde managers have in driving innovation and change are based on the combination of access to top management and knowedge of operationa capabiities. Research aso indicates that midde management invovement in strategy eads to improved decision-making, higher degrees of consensus, improved impementation and better organisationa performance. There is no reason why these observations concerning midde management work in genera shoud not appy in heath-care settings. Queen's Printer and Controer of HMSO 2013. 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. 95

MANAGEMENT CONTRIBUTIONS Institutiona context (nationa) Professiona bureaucracy Centra contro and reguation Constant reorganisation Long-term funding ice age (Chapter 3) Organisationa context (oca) Legacy issues with estate and IT Significant budget cuts Service ine divisiona sios Long strategic change agendas (Chapter 4) Acute trust management function Hybrids: pure pays - ratio 4:1 (30% of staff) Motives: make a difference, do a good job Pressures: rising workoad, fewer resources Extreme jobs: pressure, scope, pace, intensity (Chapters 2 and 5) Management capacity Capabiities Engagement Numbers Infrastructure Reationships Variety in perspectives (Chapter 2) Enabing or disabing environment? Top team communications Performance management Business inteigence systems Interprofessiona coaboration Zero non-vaue adding Support services Autonomy to innovate Persona deveopment Organisation structures Teamwork Organisationa norms Resources High performance heath-care management practices (Chapters 5 and 7) Management contributions Managing day-to-day operations Firefighting and troubeshooting Addressing wicked probems Deveoping others Systems improvements after serious incidents Championing innovation, faciitating change (Chapter 7) Cinica and organisationa outcomes Quaity and safety of patient care, financia viabiity, meeting targets, CQC and Monitor ratings FIGURE 9 A contributions-based mode of the acute trust midde management function. The arrows between the components of this mode indicate infuence and dependencies (one way or mutua) and are not intended to represent causa reationships. 96 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Factors inhibiting entrepreneuria midde managers incude poicies that encourage conservative behaviour, compex approva cyces, micromanagement and ack of deegated authority a of which were observed in this study. Factors fostering innovation incude overapping territories, cross-functiona contacts, free fows of information, excess in budgets, oosey defined roes and contact with other organisations. These propeants were ess evident, and their absence may be sustained by the divisiona sios that accompany service-ine management structures. The concept of the enabing environment is not nove. For exampe, Burns and Staker 240 showed that organic management systems operated more effectivey in turbuent environments than bureaucratic or mechanistic systems. Kanter 241 argued that integrative cutures encouraged innovation and adaptabiity, whereas segmentaist (bureaucratic) cutures did not. Severa commentators have examined the reated concept of high-performance work systems, 242,243 which invove custers of practices designed to increase capabiities, commitment, motivation and individua and organisationa performance. Huseid 244 inked high-performance work practices to higher productivity, ower staff turnover and higher corporate financia performance, such practices contributing US$18,500 per empoyee in sharehoder vaue and $4000 per empoyee in additiona profits. Pfeffer 245 caimed that high-performance practices coud raise an organisation's stock market vaue by US$20,000 40,000 per empoyee through poicies such as job security, carefu recruitment, decentraisation and sef-managing teams, remuneration inked to organisationa performance, investment in training, reduced status differentias, and information sharing across the organisation. Popuar in textbooks, high-performance practices have been ess common in practice. 246 High-performance perspectives have been appied mainy to shop foor operatives in manufacturing. Thorby and Mabin 247 ask whether or not the NHS has become a high-performing system and, athough pointing to improvements, their anaysis focuses on conditions and metrics (cancer, cardiovascuar disease, drug costs, surviva rates) and not on the organisation conditions and management practices that produce those resuts. However, Michie and West 236 deveop a high-performance framework for heath care, inking patient outcomes and organisationa performance to peope management practices that incude job design, teamwork, invovement, contro over work, eadership, and training and deveopment. The enabing environment concept is aso reated to the notion of organisation cuture. The atter has attracted mutipe definitions and is typicay operationaised in terms of organisationa properties. In contrast, the notion of enabing environment in the context of this discussion is grounded in specific poicies, behaviours and practices. From their study of organisation cutures in the NHS, Mannion et a. 248 found that the service was becoming more hierarchica and competitive, but that the inks between cuture and performance were difficut to disentange. Haq 249 reports the resuts of a survey of 132 managers attending NHS eadership programmes, concuding that ony 9% were creating a high-performance environment in which teams fet motivated and focused, whereas 77% were creating a toerabe or demotivating cimate, resuting in disengagement, minima discretionary effort and underperformance. Davenport and Harding 250 argue that a key senior management responsibiity concerns the creation and maintenance of conditions in which others can be successfu, estabishing the context for performance. Pointing to the competitive advantage in the midde of your organisation, they argue that midde managers are repositories of experience, insight and infuence, with accumuated operationa and organisationa knowedge, managing operations, deveoping others, keeping the show on the road, energising change consistent with midde management roes in heath care. Our concern in this project ies with an organisationa environment that enabes midde managers to carry out those operationa, probem-soving, service improvement and change eadership roes more effectivey. The evidence indicates that organisationa environments in acute trusts coud be more enabing and supportive. Many of the actions required to strengthen those environments are cost neutra, which is significant given the expectation that the service faces a continuing funding ice age. Hurst and Wiiams 251 therefore ask if NHS hospitas can do more with ess, pointing to the importance of eadership, management, staff engagement, improved operationa processes and new technoogy adoption. The enabing environment in Tabe 39, therefore, can Queen's Printer and Controer of HMSO 2013. 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. 97

MANAGEMENT CONTRIBUTIONS be read as a high-performance profie for midde management work. To strengthen contributions to cinica and organisationa outcomes, senior executives may wish to consider the performance dividend that woud resut from impementing cost-neutra poicies and practices such as: high-visibiity board members setting and communicating cear goas and priorities istening to and acting on ideas from staff at a eves remembering to praise the positives ensuring that management roes are seen to be recognised and vaued streamining interna governance arrangements and information requirements where possibe simpifying the provision of information to externa bodies providing appropriate and timey business and management information (activity eves, capacity, costs, outcomes), perhaps exporing simpe ow-cost IT soutions granting midde managers authority to fix probems within their own budgets aowing midde managers to act on their own initiative to piot innovations creating opportunities for the exchange of information and ideas with other organisations eiminating or at east reducing the sign-offs, which generate frustration and deays designing a rigorous and supportive performance management system with appropriate professiona support for managers who operate the system ensuring cross-divisiona information-sharing and improvement initiatives encouraging cinica manageria coaboration, to foster trust, respect and mutua understanding, and to drive major change initiatives insisting that support services human resources, finance, IT, estates adopt a customer orientation opening up opportunities for eadership and management deveopment for those with or aspiring to hod manageria responsibiities impementing team-buiding activities; good teamwork does not aways deveop naturay considering invest to save projects in which spending wi improve future cost-effectiveness. These are surey common sense actions, but the evidence suggests that they are not common in practice. In a context of rapid, radica and ongoing change, with demand rising and funding faing, in which new ways of working are at a premium, why woud an organisation not consider taking such ow-cost, ow-risk, high-return steps? Senior managers, perhaps, in restricting the autonomy and voice of midde managers, are simpy passing on down the hierarchy the pressures that they experience from nationa bodies. Another expanation perhaps rests with the composition of the midde management function, dominated by hybrids with itte management training, and who may not be trusted by more experienced executives to make appropriate management decisions. As we as buiding an enabing environment, these suggestions have other benefits. First, capabe, motivated and committed managers are more ikey to stay with an organisation that istens to their ideas, aows them to be innovative, to make a difference. In other words, these guideines constitute an effective retention strategy. Second, these steps generate ow-cost, in-house, taiored deveopment opportunities. Many midde managers participating in this project indicated that their deveopment opportunities had been curtaied by budget cuts that prevented attendance on generic externa programmes. Third, cinica staff may be more wiing to assume manageria responsibiities, and to discharge these enthusiasticay, if they know that they wi be aowed space to achieve. Finay, a of these factors contribute to management capacity, an issue raised in Chapter 2 and a research priority arising from this study. Buiding and sustaining an environment that enabes management work contributes to capacity, motivation, retention and deveopment, and increases the attractiveness of pure and hybrid midde manageria roes. Management in the pura Our board-eve contact at one trust was asked to comment on the enabing environment concept. He repied that this mode was hepfu, but requested a simper, more focused approach. His executive team woud 98 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 want to know the two or three things that woud make a big difference, the sma number of high-impact changes. In considering how to respond to that request, one theme appears to be particuary prominent: the comanagement, or shared eadership of change, by cinica and manageria staff, hybrids and pure pays, working in coaboration. Management, as with eadership, can be defined as a soution to the probem of coective effort. 252 As we have seen, hospita management is a widey distributed function, dominated by hybrids who outnumber pure pays by four to one. The capacity of that function to address effectivey the mutitude of operationa and strategic demands paced on it is therefore crucia. This appears to require what might be termed management in the pura, drawing on the coective resources of managers with different backgrounds, skis and views. The concept of distributed eadership, or eadership in the pura, 64 recognises that eadership behaviours can be seen at a eves of an organisation. The traditiona concept of focused eadership emphasises the attributes and capabiities of senior individuas. Distributed eadership concerns the achievement of goas through coective action, which may be formay designated, but can aso deveop spontaneousy. 253 255 The notion of distributed eadership is endorsed in the NHS Leadership Framework 28 and in the review of eadership and management conducted by The King's Fund. 42 Denis et a. 256 argue that a puraity of eaders may be necessary, as no one individua acting aone can combine the infuence, expertise and egitimacy needed to drive change in compex socia systems. In their review of research in this area, Denis et a. 64 aso expore the merits of conceptuaising eadership as a coective phenomenon: It is the common experience of ife within and beyond organisations that eadership and eaders are to be found in many paces. In a shared power word, pura forms of eadership where different peope bring different resources, capabiities, and sources of egitimacy (and yes, foowers) to the tabe offer a path to getting things done: not an ideaized path, and not a path that aways succeeds, but a key component of organising nonetheess that needs attention from organisationa schoars. p. 64 64 Terminoogy in this fied is aso distributed. Fitzsimons et a. 257 identify shared, distributed, dispersed, devoved, democratic, distributive, coaborative, coective, co-operative, concurrent, co-ordinated, reationa and coeadership, and then distinguish between eadership that is shared (among those hoding forma eadership roes) and eadership that is distributed (performed by many across the organisation). Martin et a. 258 distinguish between quiet distributed and quiet dispersed forms of eadership, the former being within the contro of the project in hand, the atter being more diffuse. Currie and Lockett 259 expore concertive, conjoint and coective forms of distributed eadership, identifying a spectrum between top team modes at one extreme and the spontaneous coaboration of actors pooing their expertise and skis at the other. What of shared or distributed management? Mintzberg 4 introduces these terms in a section on managing beyond the manager (p. 147). By shared managing, he means one manageria job shared among severa peope, which is not how the concept of shared eadership is understood. Distributed managing concerns the diffusion of responsibiity for some manageria roes to various non-managers in a unit (p. 152). Both concepts appear to work more cosey with forma organisationa positions and hierarchies, and do not address the more fuid, reationa, interactiona and processua eadership reays with which Denis et a. 64 and others have been concerned. Denis et a. 64 cite exampes of distributed eadership, incuding in heath care. 11 They note that these cases do not provide evidence that such forms necessariy ead to positive outcomes or that success might not have been obtained in other ways (p. 39). We have reported in this chapter, however, severa instances in which change and service improvements may not have occurred, or woud not have been impemented Queen's Printer and Controer of HMSO 2013. 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. 99

MANAGEMENT CONTRIBUTIONS so rapidy, had some form of shared eadership or shared management not been invoked to make that happen. Management in the pura is a high-impact, high-performance response to our executive. This concerns two components of the capacity mode: requisite variety and cinica manageria reationships. Pure pays and hybrids bring contrasting views to the compex probems that they face and share. There have been severa reported experiments in joint working. These incude the NHS Institute Duaity Leadership Programme, 260 the NHS London Prepare to Lead scheme, the North Western Deanery eadership deveopment programme and the London Paired Learning initiative. 53,261 Can shared management, in different forms, deveop from isoated exampes to widespread norm? Coaborative approaches, particuary in the context of diminishing resources, may be key to identifying, designing, estabishing consensus for and impementing the more innovative SDO changes necessary to improve effectiveness, quaity and safety. This discussion points to a chaenging research agenda. Currie et a. 262 show how distributed eadership is diuted by bureaucracy, power differentias and a centraised performance management regime focusing on a sma number of individuas. Denis et a. 64 note that distributed eadership may have negative outcomes, and research has not expored the discord, confict and rivaries that might arise. Gronn 254 recognises the continuing importance of hierarchica eadership aongside distributed forms. Currie and Lockett 259 aso argue that enthusiasm for distributed eadership may diute the roe of hierarchy. We therefore need to deveop a better understanding of management in the pura. In which heath-care contexts are such approaches appropriate? Which modes make the biggest difference, to those invoved, to organisationa outcomes and to patients? 100 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Acknowedgements We woud ike to dedicate this report to the memory of our coeague, Joe Jaina. Joe was instrumenta in heping to estabish this project in terms of concept and design, co-authoring the proposas and negotiating access with two of the six participating trusts. However, Joe tragicay died from cancer before he coud see those efforts rewarded. He remains a co-author of this report in recognition of his irrepaceabe contributions. We wish to thank a of the NHS staff who have contributed so much to this project by so generousy giving us their time. Staff at a eves have been wiing to share with us their experiences and ideas, despite the many pressures that the service faced as this project unfoded, and for this we are exceptionay gratefu. We woud aso ike to thank a number of members of our project team who, athough not invoved in authoring this fina report, made other vauabe contributions to the project. Jayne Ashey, our project administrator, handed the many demands that we paced on her with a cam professionaism; thanks Jayne. Catherine Baiey and Janice Osbourne made vauabe contributions to data coection and iterature reviews, and Janet Price, Kim Turnbu James and Chares Wainwright provided ongoing advice on different aspects of the project. We are aso gratefu for the support from our advisory group members who suppied us with reassurance and awkward but hepfu questions throughout: David Grantham, Katheen Hunter, Vaerie Ies, Simone Jordan, Nei Offey, Graeme Currie and Jacky Hooway. We woud aso ike to thank Dianne Bown-Wison, Eena Dodor, Marcus Durand, Charotte Gascoigne and Paua Higson for their contributions to reviewing sections of the iterature, data anaysis and interpretation and case study deveopment. Contribution of authors David A Buchanan Professor of Organisationa Behaviour Literature review, fiedwork, anaysis and report ead author David Denyer Professor of Organisationa Change Literature review, fiedwork, anaysis and Chapter 6 ead author Dr Joe Jaina Senior Lecturer in Organisationa Behaviour Project concept and design, co-author of origina proposa and site access negotiations Care Keiher Professor of Work and Organisation Fiedwork, anaysis and Chapter 6 co-author Ms Cíara Moore SDO Management Feow Fiedwork, anaysis and co-author Chapters 5 7 Dr Emma Parry Principa Research Feow Survey design and administration, anaysis and Chapter 5 co-author Dr Coin Pibeam Senior Research Feow Fiedwork, anaysis and Chapter 6 co-author Pubications See Appendix 5 for project outputs and Appendix 6 for reated pubications. Queen's Printer and Controer of HMSO 2013. 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. 101

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 References 1. Department of Heath. Equity and exceence: iberating the NHS. London: Her Majesty's Stationery Office; 2010. 2. Carise D. Managers' big worries over 20 biion target. Heath Serv J, 28 Juy 2011, pp. 19 22. 3. Ham C. More of the same is not an option. Heath Serv J, 25 March 2010, pp. 14 15. 4. Mintzberg H. Managing. Harow, Essex: Financia Times Prentice Ha; 2009. 5. Stewart R. The reaity of management, 3rd edn. London: Pan/Heinemann; 1997. 6. Watson TJ. In search of management: cuture, chaos and contro in manageria work. London: Routedge; 1994. 7. Kotter JP. What effective genera managers reay do. Harv Bus Rev 1999;77:145 59. 8. Øvretveit J, Asaksen A. The quaity journeys of six Norwegian hospitas: an action evauation. Oso: Norwegian Medica Association; 1999. 9. NHS Institute for Innovation and Improvement. Medica eadership competency framework. London: NHS Institute for Innovation and Improvement; 2008. 10. Hamiton P, Spurgeon P, Cark J, Dent J, Armit K. Engaging doctors: can doctors infuence organisationa performance? London: NHS Institute for Innovation and Improvement; 2008. 11. Buchanan DA, Addicott R, Fitzgerad L, Ferie E, Baeza J. Nobody in charge: distributed change agency in heathcare. Hum Reat 2007;60:1065 90. http://dx.doi.org/10.1177/ 0018726707081158 12. Foyd SW, Woodridge BJ. The strategic midde manager. San Francisco, CA: Jossey-Bass; 1996. 13. Huy QN. Emotiona baancing of organizationa continuity and radica change: the contribution of midde managers. Admin Sci Q 2002;47:31 69. http://dx.doi.org/10.2307/3094890 14. Badaracco JL. Leading quiety: an unorthodox guide to doing the right thing. Boston, MA: Harvard Business Schoo Press; 2002. 15. Brooks I. Leadership of a cutura change process. Leadership Org Dev J 1996;17:31 7. http://dx.doi.org/10.1108/01437739610127496 16. Lüscher LS, Lewis MW. Organizationa change and manageria sense making: working through paradox. Acad Manag J 2008;51:221 40. http://dx.doi.org/10.5465/amj.2008.31767217 17. Cark J, Spurgeon P, Dent J. Surrender to progress. Heath Serv J, 14 February 2008, pp. 32 3. 18. Locock L. Maps and journeys: redesign in the NHS. Birmingham: University of Birmingham, Heath Services Management Centre; 2001. 19. Ies V, Sutherand K. Organisationa change: a review for heath care managers, professionas and researchers. London: Nationa Co-ordinating Centre for NHS Service Deivery and Organisation Research and Deveopment; 2001. 20. Heathcare Commission. Learning from investigations. London: Commission for Heath Audit and Inspection; 2008. 21. Donadson L. An organisation with a memory. London: Department of Heath/The Stationery Office; 2000. Queen's Printer and Controer of HMSO 2013. 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. 103

REFERENCES 22. Haes C. Does it matter what managers do? Bus Strat Rev 2001;12:50 8. http://dx.doi.org/10.1111/ 1467-8616.00174 23. West MA, Borri C, Dawson J, Scuy J, Carter M, Aneay S, et a. The ink between the management of empoyees and patient mortaity in acute hospitas. Int J Hum Resource Manag 2002;13: 1299 310. http://dx.doi.org/10.1080/09585190210156521 24. Boyne GA, Meier KJ, O'Tooe LJ, Waker RM, editors. Pubic service performance: perspectives on measurement and management. Cambridge: Cambridge University Press; 2006. http://dx.doi.org/ 10.1017/CBO9780511488511 25. Dorgan S, Layton D, Boom N, Homkes R, Sadun R, Van Reenen J. Management in heathcare: why good practice reay matters. London: McKinsey & Company and London Schoo of Economics and Poitica Science; 2010. 26. Pettigrew AM, Ferie E, McKee L. Shaping strategic change: making change in arge organizations the case of the Nationa Heath Service. London: Sage Pubications; 1992. 27. Department of Heath. NHS eadership quaities framework. London: NHS Modernisation Agency Leadership Centre; 2002. 28. Nationa Leadership Counci. NHS eadership framework. London: Nationa Leadership Counci; 2011. 29. Foyd SW, Woodridge B. Midde management invovement in strategy and its association with strategic type: a research note. Strat Manag J 1992;13:153 67. http://dx.doi.org/10.1002/ smj.4250131012 30. Woodridge B, Schmid T, Foyd SW. The midde management perspective on strategy process: contributions, synthesis, and future research. J Manag 2008;34:1190 221. http://dx.doi.org/ 10.1177/0149206308324326 31. Washe K, Smith L. The NHS management workforce. London: The King's Fund; 2011. 32. Christian S, Anderson S. Review of research needs and priorities 2007. London: NHS Nationa Institute for Heath Research; 2007. 33. Department of Heath. The operating framework for the NHS in Engand 2008/09. London: Department of Heath; 2007. 34. Davies P. The NHS handbook 2010/11. London: NHS Confederation; 2010. 35. Tsoukas H. A diaogica approach to the creation of new knowedge in organizations. Organ Sci 2009;20:941 57. http://dx.doi.org/10.1287/orsc.1090.0435 36. Stake RE. Case studies. In Denzin NK, Lincon YS, editors. Handbook of quaitative research, 2nd edn. Thousand Oaks, CA: Sage Pubications; 2000. pp. 435 54. 37. Buchanan DA. Case studies in organizationa research. In Symon G, Casse C, editors. Quaitative organizationa research: core methods and current chaenges. London: Sage Pubications; 2012. pp. 373 92. 38. Toft B, Reynods S. Learning from disasters: a management approach, 3rd edn. Houndmis, Basingstoke: Pagrave Macmian; 2005. 39. Denis J-L, Lomas J. Convergent evoution: the academic and poicy roots of coaborative research. J Heath Serv Res Po 2003;8:1 5. http://dx.doi.org/10.1258/135581903322405108 40. Buchanan DA. Good practice, not rocket science: understanding faiures to change after extreme events. J Change Manag 2011;11:273 88. http://dx.doi.org/10.1080/14697017.2011.597571 104 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 41. Edwards N. Managers: can the NHS manage without them? London: Socia Market Foundation; 2004. 42. The King's Fund. The future of eadership and management in the NHS: no more heroes. London: The King's Fund; 2011. 43. Santry C. Aboishing targets wi reduce the need for managers, David Cameron says. Heath Serv J, 11 January 2010, p. 10. 44. House of Commons Heath Committee. Commissioning: fourth report of session 2009 10. London: The Stationery Office; 2010. 45. Ham C. NHS managers are the wrong targets for cuts. The Guardian, 22 February 2012, p. 36. 46. Appeby J. Cut and run. Heath Serv J, 5 Juy 2001. URL: www.hsj.co.uk/cut-and-run/24493.artice (accessed 22 February 2012). 47. McLean A. We need NHS managers to tacke the first financia crisis since 1987. Heath Serv J, 21 October 2010, p. 3. 48. Ham C. It makes a wecome change to hear praise for NHS managers. Heath Serv J, 10 February 2011. URL: www.hsj.co.uk/comment/opinion/it-makes-a-wecome-change-to-hear-praise (accessed 22 February 2012). 49. NHS Confederation. Management in the NHS: the facts. London: NHS Confederation; 2007. 50. NHS Information Centre. NHS occupation code manua version 9 (effective from 1 December 2010). URL: www.ic.nhs.uk/artice/2268/nhs-occupation-codes (accessed 28 February 2012). 51. Currie G, Procter SJ. The antecedents of midde managers' strategic contribution: the case of a professiona bureaucracy. J Manag Stud 2005;42:1325 56. http://dx.doi.org/10.1111/j. 1467-6486.2005.00546.x 52. Guick L, Urwick L. Papers on the science of administration. New York, NY: Institute of Pubic Administration; 1937. 53. Giam S. Teaching doctors in training about management and eadership. BMJ 2011;343:1 2. http://dx.doi.org/10.1136/bmj.d5672 54. Learmonth M. Doing things with words: the case of management' and administration'. Pub Admin 2005;83:617 37. http://dx.doi.org/10.1111/j.0033-3298.2005.00465.x 55. O'Reiy D, Reed M. Leaderism: an evoution of manageriaism in UK pubic service reform. Pub Admin 2010;88:960 78. http://dx.doi.org/10.1111/j.1467-9299.2010.01864.x 56. Quinn RE, Faerman SR, Thompson MP, McGrath MR, St Cair LS. Becoming a master manager: a competing vaues approach, 5th edn. New York, NY: John Wiey; 2011. 57. Haes C. Moving down the ine?: the shifting boundary between midde and first-ine management. J Gen Manag 2006;32:31 55. 58. Baogun J. From baming the midde to harnessing its potentia: creating change intermediaries. Br J Manag 2003;14:69 83. http://dx.doi.org/10.1111/1467-8551.00266 59. Shi WS, Markoczy L, Dess GG. The roe of midde management in the strategy process: group affiiation, structura hoes, and tertius iungens. J Manag 2009;35:1453 80. http://dx.doi.org/ 10.1177/0149206309346338 60. Inamdar SN, Osand A, Wes P. Restructuring with the midde-management advantage. Heath Care Manag 2010;29:305 17. 61. Moore A. A icense to manage? Heath Serv J Regu Supp, 13 October 2011, pp. 1 7. Queen's Printer and Controer of HMSO 2013. 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. 105

REFERENCES 62. Ashby WR. An introduction to cybernetics. London: Chapman & Ha; 1956. 63. Shrivastava S, Sonpar K, Pazzagia F. Norma accident theory versus high reiabiity theory: a resoution and ca for an open systems view of accidents. Hum Reat 2009;62:1357 90. http://dx.doi.org/10.1177/0018726709339117 64. Denis J-L, Langey A, Sergi V. Leadership in the pura. Acad Manag Ann 2012;6:1 73. 65. Suddaby R, Esbach KD, Greenwood R, Meyer JW, Ziber TB. Organizations and their institutiona environments: bringing meaning, vaues and cuture back in. Acad Manag J 2010;53:1234 40. http://dx.doi.org/10.5465/amj.2010.57317486 66. Dopson S, Fitzgerad L. The active roe of context. In Dopson S, Fitzgerad L, editors. Knowedge to action: evidence-based heath care in context. Oxford: Oxford University Press; 2005. pp. 79 103. http://dx.doi.org/10.1093/acprof:oso/9780199259014.003.0005 67. Buchanan DA, Fitzgerad L. New ock, new stock, new barre, same gun: the accessorized bureaucracy of heathcare. In Cegg S, Harris M, Höpf H, editors. Managing modernity: beyond bureaucracy? Oxford: Oxford University Press; 2011. pp. 56 80. 68. Abraham A. Care and compassion: report of the heath service ombudsman on ten investigations into NHS care of oder peope. London: The Stationery Office; 2011. 69. Care Quaity Commission. Review of compiance: Castebeck Care (Teesdae) Ltd. Newcaste upon Tyne: Care Quaity Commission; 2011. 70. Francis R. Independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 March 2009 (two voumes). London: The Stationery Office; 2010. 71. Kitchener M. A fur coat and no knickers: contemporary organizationa change in United Kingdom hospitas. In Brock DM, Powe MJ, Hinings CR, editors. Restructuring the Professiona organization: accounting, heath care and aw. London: Routedge; 1999. pp. 183 248. http://dx.doi.org/ 10.4324/9780203018446.ch9 72. Nichoson D. The year: NHS chief executive's annua report 2008/09. London: Department of Heath; 2009. 73. Osen JP. Maybe it is time to rediscover bureaucracy. J Pub Admin Res Theor 2006;16:1 24. http://dx.doi.org/10.1093/jopart/mui027 74. Leavitt HJ. Top down: why hierarchies are here to stay and how to manage them more effectivey. Boston, MA: Harvard Business Schoo Press; 2005. 75. Department of Heath. High quaity care for a: NHS next stage review fina report. London: Department of Heath; 2008. 76. Department of Heath. High quaity care for a: our journey so far. London: Department of Heath; 2009. 77. Department of Heath. The operating framework for the NHS in Engand 2010/11. London: Department of Heath; 2009. 78. Heathcare Commission. Investigation into Mid Staffordshire NHS Foundation Trust. London: Commission for Heath Audit and Inspection; 2009. 79. West D. MPs: NHS white paper acked credibe pan. Heath Serv J, 18 January 2011, p. 10. 80. House of Commons Heath Committee. Foundation trusts and Monitor. London: The Stationery Office; 2008. 81. Jones D, Mitche A. Lean thinking for the NHS. London: NHS Confederation; 2006. 106 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 82. Powe AE, Rushmer RK, Davies HTO. A systematic narrative review of quaity improvement modes in heathcare. Edinburgh: NHS Quaity Improvement Scotand; 2009. 83. Staney S, Eaton M. Powerfu change for pathoogy. Heath Serv J, 22 September 2011, pp. 28 9. 84. Juius D. Understanding the pubic services industry: how big, how good, where next? London: Department for Business, Enterprise and Reguatory Reform; 2008. 85. Boye C, Lewis C. Competition check-up for private care. The Times, 15 December 2010, pp. 38 9. 86. Barrow M, Smyth C. Lives at risk as hospitas run into cash crisis. The Times, 13 December 2011, p. 1. 87. Smyth C, Asthana A. Expansion of private care in NHS hospitas. The Times, 27 December 2011, pp. 1, 6. 88. Britne M. How the NHS coud make money for Britain. The Times, 15 November 2011, p. 24. 89. Department of Heath. Liberating the NHS: report of the arm's-ength bodies review. London: Department of Heath; 2010. 90. Department of Heath. NHS 2010 2015: from good to great. London: The Stationery Office; 2009. 91. Edwards N. Ony our best can sove this puzze. Heath Serv J, 30 June 2011, pp. 16 17. 92. Propper C, Sutton M, Whitna C, Windmeijer F. Did targets and terror' reduce waiting times in Engand for hospita care? B.E. J Econ Ana Poi 2008;8:1 25. http://dx.doi.org/10.2202/1935-1682.1863 93. Edwards N, Lewis R. Baancing externa requirements and a positive interna cuture. London: The King's Fund; 2011. 94. NHS Confederation. What's it a for?: removing unnecessary bureaucracy in reguation. London: NHS Confederation and Independent Heathcare Advisory Services; 2009. 95. Monitor. Compiance framework 2011 12. London: Monitor; 2011. 96. Care Quaity Commission. Guidance about compiance with the Heath and Socia Care Act 2008 (registration requirements) reguations 2009. London: Care Quaity Commission; 2009. 97. Care Quaity Commission. How we monitor compiance. London: Care Quaity Commission; 2011. 98. Care Quaity Commission. Essentia standards of quaity and safety. London: Care Quaity Commission; 2010. 99. Department of Heath. Revision to the operating framework for the NHS in Engand 2010/11. London: Department of Heath; 2010. 100. Department of Heath. The NHS outcomes framework 2012/13. London: Department of Heath; 2011. 101. Department of Heath. Innovation, heath and weath: acceerating adoption and diffusion in the NHS. Leeds: Department of Heath; 2011. 102. Santry C. Weak managers coud be struck off. Heath Serv J, 4 March 2010, pp. 4 5. 103. Counci for Heathcare Reguatory Exceence. Standards for members of NHS boards and governing bodies in Engand. London: Counci for Heathcare Reguatory Exceence; 2012. 104. Department of Heath. The operating framework for the NHS in Engand 2008/09. London: Department of Heath; 2007. 105. Appeby J. An NHS ice age may have ony just begun. Heath Serv J, 1 June 2011, p. 6. Queen's Printer and Controer of HMSO 2013. 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. 107

REFERENCES 106. Gainsbury S. Financia directors fee a distinct nip in the air. Heath Serv J, 31 March 2010, pp. 12 13. 107. Department of Heath. The operating framework for the NHS in Engand 2012/13. London: Department of Heath; 2011. 108. Dower C, Cover B. Pressure pies up on acute hospita sector. Heath Serv J, 1 December 2011, pp. 4 5. 109. Cover B. Dozens of trusts missed savings target in 2010 11. Heath Serv J, 9 June 2011, pp. 6 7. 110. Davies N. Fat Earth News. London: Vintage Books; 2009. 111. West D. Future Forum demands end to manager bashing. Heath Serv J, 17 June 2011, p. 9. 112. Christensen CM, Bohmer R, Kenagy J. Wi disruptive innovations cure heath care? Harv Bus Rev 2000;78:102 12. 113. Monitor. Service-ine management: an overview. London: Monitor; 2009. 114. Maby B. Suited must not mean booted. Heath Serv J, 19 May 2011, pp. 18 19. 115. Bruch H, Menges JI. The acceeration trap. Harv Bus Rev 2010;88:80 6. 116. Scase R, Goffee R. Reuctant managers: their work and ifestyes. London: Routedge; 1989. 117. Whyte WH. The organization man. Harmondsworth, Middesex: Penguin Books; 1956. 118. Daton M. Men who manage. New York, NY: Wiey; 1959. 119. Mintzberg H. The nature of manageria work. London: Harper Coins; 1973. 120. Mintzberg H. Rounding out the manageria job. Soan Manag Rev 1994;36:11 26. 121. Hassan F. The frontine advantage. Harv Bus Rev 2011;89:106 14. 122. Huy QN. In praise of midde managers. Harv Bus Rev 2001;79:72 9. 123. Badaracco JL. We don't need another hero. Harv Bus Rev 2001;79:121 6. 124. Meyerson DE. Radica change, the quiet way. Harv Bus Rev 2001;79:92 100. 125. Meyerson DE. Tempered radicas: how peope use difference to inspire change at work. Boston, MA: Harvard Business Schoo Press; 2001. 126. Davenport TH, Prusak L, Wison HJ. Who's bringing you hot ideas and how are you responding? Harv Bus Rev 2003;81:58 64. 127. Dopson S, Stewart R. What is happening to midde management? Br J Manag 1990;1:3 16. http://dx.doi.org/10.1111/j.1467-8551.1990.tb00151.x 128. Hassard J, McCann L, Morris J. Managing in the modern corporation: the intensification of manageria work in the USA, UK and Japan. Cambridge: Cambridge University Press; 2009. http://dx.doi.org/10.1017/cbo9780511642180 129. Hyde P, Granter E, McCann L, Hassard J. The ost heath service tribe: in search of midde managers. In Dickinson H, Mannion R, editors. The reform of heath care: shaping, adapting and resisting poicy deveopments. Houndmis, Basingstoke: Pagrave Macmian; 2012. pp. 7 20. 130. Carney M. Midde manager invovement in strategy deveopment in not-for-profit organizations: the director of nursing perspective. J Nurs Manag 2004;12:13 21. http://dx.doi.org/10.1111/ j.1365-2834.2004.00388.x 108 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 131. Pappas JM, Faherty KE, Woodridge B. Tapping into hospita champions: strategic midde managers. Heath Care Manag Rev 2004;29:8 16. http://dx.doi.org/10.1097/00004010-200401000-00003 132. Currie G. Reuctant but resourcefu midde managers: the case of nurses in the NHS. J Nurs Manag 2006;14:5 12. http://dx.doi.org/10.1111/j.1365-2934.2005.00613.x 133. Boton SC. Mutipe roes?: nurses as managers in the NHS. Int J Pub Sector Manag 2003;16: 122 30. http://dx.doi.org/10.1108/09513550310467975 134. Gough R, Fitzpatrick M. Reuctant managers: nurses surviving despite the bottom ine. N Z J Empoy Reat 2004;29:49 66. 135. Thorpe K, Loo R. Baancing professiona and persona satisfaction of nurse managers: current and future perspectives in a changing heath care system. J Nurs Manag 2003;22:400 15. 136. Loo R, Thorpe K. Making femae first-ine nurse managers more effective: a Dephi study of occupationa stress. Women Manag Rev 2004;19:88 96. http://dx.doi.org/10.1108/ 09649420410525298 137. Wise S. Wanted: the next generation of nurse and midwifery managers. Int J Pub Sector Manag 2007;20:473 83. http://dx.doi.org/10.1108/09513550710818368 138. Bergin E. On becoming a manager and attaining manageria integrity. Leader Heath Serv 2009;22:58 75. http://dx.doi.org/10.1108/17511870910928029 139. Leweyn S. Two-way windows': cinicians as medica managers. Organ Stud 2001;22:593 623. http://dx.doi.org/10.1177/0170840601224003 140. Savage J, Scott C. The modern matron: a hybrid management roe with impications for continuous quaity improvement. J Nurs Manag 2004;12:419 26. http://dx.doi.org/10.1111/j. 1365-2834.2004.00511.x 141. Forbes T, Haier J, Key L. Doctors as managers: investors and reuctants in a dua roe. Heath Serv Manag Res 2004;17:167 76. http://dx.doi.org/10.1258/0951484041485638 142. Sargent P, Pickard S, Sheaff R, Boaden R. Patient and carer perceptions of case management for ong term conditions. Heath Soc Care Community 2007;15:511 19. http://dx.doi.org/10.1111/ j.1365-2524.2007.00708.x 143. Currie G, Koteyko N, Nerich B. The dynamics of professions and deveopment of new roes in pubic services organizations: the case of modern matrons in the Engish NHS. Pub Admin 2009;87: 295 311. http://dx.doi.org/10.1111/j.1467-9299.2009.01755.x 144. Wikström E, Deve L. Contemporary eadership in heathcare organizations: fragmented or concurrent eadership. J Heath Organ Manag 2009;23:411 28. http://dx.doi.org/10.1108/ 14777260910979308 145. Preston D, Loan-Carke J. The NHS manager: a view from the bridge. J Manag Med 2000;14:100 8. http://dx.doi.org/10.1108/02689230010346411 146. Eina V, Juhani L, Tiina T, Kari M, Irma V, Mauri I, et a. Doctor-managers as decision makers in hospitas and heath centres. J Heath Organ Manag 2006;20:85 94. http://dx.doi.org/10.1108/ 14777260610661493 147. Vaentino CL. The roe of midde managers in the transmission and integration of organizationa cuture. J Heathc Manag 2004;49:393 404. 148. Embertson MK. The importance of midde managers in heathcare organizations. J Heathc Manag 2006;51:223 32. Queen's Printer and Controer of HMSO 2013. 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. 109

REFERENCES 149. Porter S, Anderson L, Chetty A, Dyker S, Murphy F, Cheyne H, et a. Operationa competency deveopment in E and F grade nursing staff: preparation for management. J Nurs Manag 2006;14:384 90. http://dx.doi.org/10.1111/j.1365-2934.2006.00628.x 150. Waters D, Carke M, Inga A, Dean-Jones M. Evauation of a piot mentoring programme for nurse managers. J Adv Nurs 2003;42:516 26. http://dx.doi.org/10.1046/j.1365-2648.2003.02651.x 151. Pafrey C, Thomas P, Phiips C. Heath services management: what are the ethica dimensions? Int J Pub Sector Manag 2006;19:57 66. http://dx.doi.org/10.1108/09513550610640393 152. Merai F. NHS managers' views of their cuture and their pubic image: the impications for NHS reforms. Int J Pub Sector Manag 2003;16:549 63. http://dx.doi.org/10.1108/ 09513550310500409 153. NHS Confederation. Management matters: how NHS managers are making a difference. London: NHS Confederation; 2003. 154. Crawford P, Brown B. Soft authority: ecoogies of infection management in the working ives of modern matrons and infection contro staff. Socio Heath In 2008;30:756 71. http://dx.doi.org/10.1111/j.1467-9566.2008.01086.x 155. Scott J. Management retention in the NHS. J Manag Med 2002;6:292 302. 156. Forbes T, Haier J. Socia identify and sef-enactment strategies: adapting to change in professiona manager reationships in the NHS. J Nurs Manag 2006;14:34 42. http://dx.doi.org/ 10.1111/j.1365-2934.2005.00614.x 157. Carney M. Heath service management: cuture, consensus and the midde manager. Cork: Oak Tree Press; 2006. 158. Dopson S, Fitzgerad L. The roe of the midde manager in the impementation of evidence-based heath care. J Nurs Manag 2006;14:43 51. http://dx.doi.org/10.1111/j.1365-2934.2005.00612.x 159. Hewison A. Manageria vaues and rationaity in the UK Nationa Heath Service. Pub Manag Rev 2002;44:549 79. http://dx.doi.org/10.1080/14616670210164762 160. Cathcart EB, Greenspan M, Quin M. The making of a nurse manager: the roe of experientia earning in eadership deveopment. J Nurs Manag 2010;18:440 7. http://dx.doi.org/10.1111/ j.1365-2834.2010.01082.x 161. Goud D. The matron's roe in acute Nationa Heath Service trusts. J Nurs Manag 2008;16:804 12. http://dx.doi.org/10.1111/j.1365-2834.2008.00880.x 162. Doherty C. A quaitative study of heath service reform on nurses' working ives: earning from the UK Nationa Heath Service. Int J Nurs Stud 2009;46:1134 42. http://dx.doi.org/10.1016/j. ijnurstu.2009.01.014 163. Haier J, Forbes T. The roe of socia identity in doctors' experiences of cinica managing. Empoyee Reat 2005;27:47 70. http://dx.doi.org/10.1108/01425450510569300 164. Cameron D. The NHS wi sicken uness we modernise. The Times, 31 January 2011, p. 20. 165. Cook J, Wa T. New work attitude measures of trust, organisationa commitment and persona need non-fufiment. J Occup Psycho 1980;53:39 52. http://dx.doi.org/10.1111/j.2044-8325.1980.tb00005.x 166. Rose M. The costs of a career in minutes and morbidity. In Houston DM, editor. Work ife baance in the 21st century. Houndmis, Basingstoke: Pagrave Macmian; 2005. pp. 29 54. 167. Hewett SA, Luce CB. Extreme jobs: the dangerous aure of the 70-hour workweek. Harv Bus Rev 2006;84:49 59. 110 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 168. Medica Women's Federation. Making part-time work. London: Medica Women's Federation; 2008. 169. Ng TWH, Fedman DC. Long work hours: a socia identity perspective on meta-anaysis data. J Organ Behav 2008;29:853 80. http://dx.doi.org/10.1002/job.536 170. Pfeffer J. Buiding sustainabe organizations: the human factor. Acad Manag Perspect 2010;24: 34 45. http://dx.doi.org/10.5465/amp.2010.50304415 171. Burke RJ, Fiksenbaum L. Manageria and professiona women in extreme jobs': benefits and costs. Equa Opportun Int 2000;28:432 42. http://dx.doi.org/10.1108/02610150910964277 172. Burke RJ, Fiksenbaum L. Are manageria women in extreme jobs' disadvantaged? Gender Manag 2009;24:5 13. http://dx.doi.org/10.1108/17542410910930716 173. Sergeant A. NHS chief executives: bod and od. London: Hoggett Bowers; 2009. 174. Lewis R, Donadson-Feider E, Pangao A. Deveoping resiience. London: Chartered Institute for Personne and Deveopment; 2011. 175. Cornum R, Matthews MD, Seigman MEP. Comprehensive sodier fitness: buiding resiience in a chaenging institutiona context. Am Psycho 2011;66:4 9. http://dx.doi.org/10.1037/a0021420 176. Wrzesniewski A, Dutton JE. Crafting a job: revisioning empoyees as active crafters of their work. Acad Manag Rev 2001;26:179 201. 177. Rousseau DM, Ho VT, Greenberg J. I-deas: idiosyncratic terms in empoyment reationships. Acad Manag Rev 2006;31:977 94. http://dx.doi.org/10.5465/amr.2006.22527470 178. Perow LA. Time to coordinate: toward an understanding of work-time standards and norms in a muticountry study of software engineers. Work Occup 2001;28:91 111. http://dx.doi.org/ 10.1177/0730888401028001006 179. Cover B. Acute sector faces unprecedented shake-up. Heath Serv J, 29 March 2012, pp. 6 7. 180. Dower C. Monitor chair admits it must get tougher. Heath Serv J, 29 March 2012, pp. 4 5. 181. Care Quaity Commission. Review of the invovement and action taken by heath bodies in reation to the case of Baby P. London: Care Quaity Commission; 2009. 182. Laming W. The protection of chidren in Engand: a progress report. London: The Stationery Office; 2009. 183. Laming W. The Victoria Cimbié inquiry. Norwich: Her Majesty's Stationery Office; 2003. 184. British Broadcasting Corporation (BBC). Fie on 4: chid protection poicies. Programme number 08VQ3930LHO, London, 2008. 185. Keer S, Meaney M, Pung C. What successfu transformations share. Chicago, IL: McKinsey; 2010. 186. Washe K, Higgins J. The use and impact of inquiries in the NHS. BMJ 2002;325:895 900. http://dx.doi.org/10.1136/bmj.325.7369.895 187. Nationa Heath Service Litigation Authority. Report and accounts 2010. London: The Stationery Office; 2010. 188. Sherman J. NHS forced into baiout as damage caims soar. The Times, 12 January 2012, pp. 1 10. 189. Kohn LT, Corrigan JM, Donadson MS, editors. To err is human: buiding a safer heath system. Washington, DC: Institute of Medicine, Nationa Academy Press; 2000. 190. Turner B, Pidgeon N. Man-made disasters, 2nd edn. London: Butterworth Heinemann; 1997. 191. Reason J. Managing the risks of organizationa accidents. Adershot: Ashgate Pubishing; 1997. Queen's Printer and Controer of HMSO 2013. 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. 111

REFERENCES 192. Gardner D. Risk: the science and poitics of fear. London: Virgin Books/Random House; 2008. 193. McGraw AP, Todorov A, Kunreuther H. A poicy maker's diemma: preventing terrorism or preventing bame. Organ Behav Hum Dec 2011;115:25 34. http://dx.doi.org/10.1016/j. obhdp.2011.01.004 194. Eiott D, Swartz E, Herbane B. Business continuity management: a crisis management approach, 2nd edn. London: Routedge; 2010. 195. Weick KE. The coapse of sensemaking in organizations: the Mann Guch disaster. Admin Sci Q 1993;38:628 52. http://dx.doi.org/10.2307/2393339 196. Vaughan D. The Chaenger aunch decision: risky technoogy, cuture, and deviance at NASA. Chicago, IL: University of Chicago Press; 1996. 197. Snook SA. Friendy fire: the accidenta shootdown of US Back Hawks over Northern Iraq. Princeton, NJ: Princeton University Press; 2000. 198. Perrow C. Norma accidents: iving with high-risk technoogies. Princeton, NJ: Princeton University Press; 1999. 199. Carro JS. Organizationa earning activities in high-hazard industries: the ogics underying sef-anaysis. J Manag Stud 1998;35:699 717. http://dx.doi.org/10.1111/1467-6486.00116 200. Brown AD. Authoritative sensemaking in a pubic inquiry report. Organ Stud 2003;25:95 112. http://dx.doi.org/10.1177/0170840604038182 201. Vogus TJ, Sutciffe KM, Weick KE. Doing no harm: enabing, enacting, and eaborating a cuture of safety in heath care. Acad Manag Perspect 2010;24:60 77. http://dx.doi.org/10.5465/ AMP.2010.55206385 202. Honage E, Woods DD, Leveson N, editors. Resiience engineering: concepts and precepts. Adershot, Hampshire: Ashgate Pubishing; 2006. 203. Weick KE, Sutciffe KM. Managing the unexpected: resiient performance in an age of uncertainty. San Francisco, CA: Jossey-Bass; 2007. 204. Maher JG, Casamayou MH. Organizationa earning at NASA: the Chaenger and Coumbia accidents. Washington, DC: Georgetown University Press; 2009. 205. Eiott D. The faiure of organisationa earning from crisis: a matter of ife and death? J Conting Crisis Manag 2009;17:157 68. http://dx.doi.org/10.1111/j.1468-5973.2009.00576.x 206. Leveson N. A new accident mode for engineering safer systems. Saf Sci 2004;42:237 70. http://dx.doi.org/10.1016/s0925-7535(03)00047-x 207. Reason J. Human error: modes and management. BMJ 2000;320:768 70. http://dx.doi.org/10.1136/bmj.320.7237.768 208. Qureshi ZH. A review of accident modeing approaches for compex critica sociotechnica systems. Edinburgh, South Austraia: Defence Science and Technoogy Organisation; 2008. 209. Rasmussen J. Risk management in a dynamic society: a modeing probem. Saf Sci 1997;27: 183 213. http://dx.doi.org/10.1016/s0925-7535(97)00052-0 210. Rasmussen J, Svedung I. Proactive risk management in a dynamic society. Karstad: Swedish Rescue Services Agency; 2000. 211. Vincent C, Tayor-Adams S, Stanhope N. Framework for anaysing risk and safety in cinica medicine. BMJ 1998;316:1154 7. http://dx.doi.org/10.1136/bmj.316.7138.1154 212. The Heath Foundation. How safe are cinica systems? London: The Heath Foundation; 2011. 112 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 213. Nicoini D, Waring J, Mengis J. The chaenges of undertaking root cause anaysis in heath care: a quaitative study. J Heath Serv Res Po 2011;16:34 41. http://dx.doi.org/10.1258/ jhsrp.2010.010092 214. Nicoini D, Waring J, Mengis J. Poicy and practice in the use of root cause anaysis to investigate cinica adverse events: mind the gap. Soc Sci Med 2011;73:217 25. http://dx.doi.org/10.1016/j. socscimed.2011.05.010 215. Horn RE, Weber RP. New toos for resoving wicked probems: mess mapping and resoution mapping processes. San Francisco, CA: Stanford University, Macro VU(r) and Strategy Kinetics; 2007. 216. Ross L. The intuitive psychoogist and his shortcomings: distortions in the attribution process. In Berkowitz L, editor. Advances in experimenta socia psychoogy. New York: Academic Press; 1977. pp. 173 220. 217. Ritte HWJ, Webber MM. Diemmas in a genera theory of panning. Po Sci 1973;4:155 69. http://dx.doi.org/10.1007/bf01405730 218. Weick KE, Roberts KH. Coective mind in organizations: heedfu interreating on fight decks. Admin Sci Q 2003;38:357 81. http://dx.doi.org/10.2307/2393372 219. Vincent C, Benn J, Hanna G. High reiabiity in heathcare. BMJ 2010;340:225 6. http://dx.doi.org/ 10.1136/bmj.c84 220. Guth WD, MacMian IC. Strategy impementation versus midde manager sef-interest. Strat Manag J 1986;7:313 27. http://dx.doi.org/10.1002/smj.4250070403 221. Meyer CB. Destructive dynamics of midde management intervention in postmerger processes. J App Behav Sci 2006;42:397 419. http://dx.doi.org/10.1177/0021886306289420 222. Siince J, Mueer F. Switching strategic perspective: the reframing of accounts of responsibiity. Organ Stud 2007;28:155 76. http://dx.doi.org/10.1177/0170840606067989 223. Bower JL. Managing the resource aocation process. Boston, MA: Graduate Schoo of Business Administration, Harvard University; 1970. 224. Kanter RM. The midde manager as innovator. Harv Bus Rev 1982;60:95 105. 225. Woodridge BJ, Foyd SW. The strategy process, midde management invovement, and organizationa performance. Strat Manag J 1990;11:231 41. http://dx.doi.org/10.1002/ smj.4250110305 226. Foyd SW, Woodridge B. Midde managers' strategic infuence and organizationa performance. J Manag Stud 1997;34:465 85. http://dx.doi.org/10.1111/1467-6486.00059 227. Roueau L, Baogun J. Midde managers, strategic sensemaking, and discursive competence. J Manag Stud 2011;48:953 83. http://dx.doi.org/10.1111/j.1467-6486.2010.00941.x 228. Boyett I, Currie G. Midde managers mouding internationa strategy: an Irish start-up in Jamaican teecoms. Long Range Pann 2004;37:51 66. http://dx.doi.org/10.1016/j.rp.2003.11.009 229. Mair J. Exporing the determinants of unit performance: the roe of midde managers in stimuating profit growth. Group Organ Manag 2005;30:263 88. http://dx.doi.org/10.1177/ 1059601104269113 230. Kuratko DF, Godsby MG. Corporate entrepreneurs or rogue midde managers?: a framework for ethica corporate entrepreneurship. J Bus Ethics 2004;55:13 30. http://dx.doi.org/10.1007/s10551-004-1775-3 231. Baogun J. When organisations change: a midde management perspective on getting it right. London: Advanced Institute of Management Research; 2008. Queen's Printer and Controer of HMSO 2013. 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. 113

REFERENCES 232. West M, Johnson R. A matter of ife and death. Peope Manag 2002;8:30 6. 233. Santry C. Quaity strongy inked to increase in managers. Heath Serv J, 11 February 2010, pp. 4 5. 234. Hutton J, Caow C. NHS eaders are key to innovation. Heath Serv J, 8 Juy 2010, p. 24. 235. Purce J, Kinnie N, Hutchinson S, Rayton B, Stuart J. Understanding the peope and performance ink: unocking the back box. London: Chartered Institute for Personne and Deveopment; 2003. 236. Michie S, West M. Managing peope and performance: an evidence based framework appied to heath service organizations. Int J Manag Rev 2004;5/6:91 111. http://dx.doi.org/10.1111/j.1460-8545.2004.00098.x 237. Boom N, Van Reenen J. Why do management practices differ across firms and countries? J Econ Perspect 2010;24:203 24. http://dx.doi.org/10.1257/jep.24.1.203 238. West M, Dawson J, Admasachew L, Topakas A. NHS staff management and heath service quaity. London: Department of Heath; 2011. 239. West M, Guthrie JP, Dawson AF, Carter M. Reducing patient mortaity in hospitas: the roe of human resource management. J Organ Behav 2006;27:983 1002. http://dx.doi.org/ 10.1002/job.396 240. Burns T, Staker GM. The management of innovation. London: Tavistock Pubications; 1961. 241. Kanter RM. The change masters: corporate entrepreneurs at work. London: George Aen & Unwin; 1983. 242. Buchanan DA, McCaman J. High performance work systems: the digita experience. London: Routedge; 1989. 243. Lawer EE, Mohrman SA, Ledford GE. Strategies for high performance organizations. San Francisco, CA: Jossey-Bass; 1998. 244. Huseid MA. The impact of human resource management practices on turnover, productivity, and corporate financia performance. Acad Manag J 1995;38:635 72. http://dx.doi.org/10.2307/ 256741 245. Pfeffer J. The human equation: buiding profits by putting peope first. Boston, MA: Harvard Business Schoo Press; 1998. 246. Guest D, King Z. Personne's paradox. Peope Manag 2001;7:24 9. 247. Thorby R, Mabin J. A high performing NHS?: a review of progress 1997 2010. London: The King's Fund; 2010. 248. Mannion R, Davies H, Harrison S, Konteh F, Greener I, McDonad R, et a. Changing management cutures and organizationa performance in the NHS. London: Queen's Printer and Controer of HMSO; 2010. 249. Haq L. Lead from the midde. Heath Serv J, 10 November 2011, pp. 23 5. 250. Davenport TO, Harding SD. The manager redefined: the competitive advantage in the midde of your organization. San Francisco, CA: Jossey-Bass; 2010. 251. Hurst J, Wiiams S. Can NHS hospitas do more with ess? London: Nuffied Trust; 2012. 252. Kaiser RB, Hogan R, Craig SB. Leadership and the fate of organizations. Am Psycho 2008; 63:96 110. http://dx.doi.org/10.1037/0003-066x.63.2.96 253. Gronn P. Distributed eadership as a unit of anaysis. Leader Q 2002;13:423 51. http://dx.doi.org/10.1016/s1048-9843(02)00120-0 114 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 254. Gronn P. Leadership configurations. Leadership 2009;5:381 94. http://dx.doi.org/10.1177/ 1742715009337770 255. Hernandez M, Ebery MB, Avoio BJ, Johnson MD. The oci and mechanisms of eadership: exporing a more comprehensive view of eadership theory. Leader Q 2011;22:1165 85. http://dx.doi.org/10.1016/j.eaqua.2011.09.009 256. Denis J-L, Langey A, Roueau L. Strategizing in puraistic contexts: rethinking theoretica frames. Hum Reat 2007;60:179 215. http://dx.doi.org/10.1177/0018726707075288 257. Fitzsimons D, James KT, Denyer D. Aternative approaches for studying shared and distributed eadership. Int J Manag Rev 2011;13:313 28. http://dx.doi.org/10.1111/j.1468-2370.2011.00312.x 258. Martin GP, Currie G, Finn R. Leadership, service reform, and pubic service networks: the case of cancer-genetics piots in the Engish NHS. J Pub Admin Res Theor 2009;19:769 94. http://dx.doi.org/10.1093/jopart/mun016 259. Currie G, Lockett A. Distributing eadership in heath and socia care: concertive, conjoint or coective? Int J Manag Rev 2011;13:286 300. http://dx.doi.org/10.1111/j.1468-2370.2011.00308.x 260. Atkinson S, Spurgeon P, Cark J, Armit K. Engaging doctors: what can we earn from trusts with high eves of medica engagement? Coventry: NHS Institute for Innovation and Improvement; 2011. 261. Kaber B, Lee J, Abraham R, Lemer C, Smith L. How pairing cinicians with managers coud speed up cinica exceence. Heath Serv J, 22 September 2011, pp. 21 3. 262. Currie G, Grubnic S, Hodges R. Leadership in pubic services networks: antecedents, process and outcome. Pub Admin 2011;89:242 60. http://dx.doi.org/10.1111/j.1467-9299.2011.01931.x Queen's Printer and Controer of HMSO 2013. 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. 115

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Appendix 1 Research protoco Research protoco Version 1: 09.02.2009 Cranfied University Schoo of Management and Cranfied Heath NHS Nationa Institute for Heath Research Service Deivery and Organization Research Programme 241 Management Practice in Heathcare Organizations: proposa #0001926 How do they manage?: research protoco A study of the reaities of midde and front ine management work in heathcare Three and a haf years, starting January 2009 Research team: Professor David A. Buchanan Dr Catherine Baiey Dr David Denyer Dr Care Keiher Ms Cíara Moore Dr Janice Osbourne Dr Emma Parry Dr Coin Pibeam Dr Janet Price Professor Kim Turnbu-James Dr Chares Wainwright Scientific summary Managers constitute 3 per cent of the NHS workforce. That figure underestimates the impact of management practice on cinica outcomes, quaity of patient care, and organizationa performance. The NHS has concentrated on senior eadership, and ess is known about the experience and attitudes of midde and front ine managers in acute care, who are the focus of this project. Exporing the reaities of Queen's Printer and Controer of HMSO 2013. 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. 117

APPENDIX 1 management work, their roe in change, and inks between practice and performance, this study has four aims. The first is to contribute to the practice and theory of heathcare management in order to improve patient care and organizationa performance. The second is to provide evidence-based guidance for management deveopment, strengthening the impact of management practices on hospita performance, streamining the impementation of changes foowing adverse events in the interests of patient safety. These first two aims wi be achieved with new perspectives, approaches, frameworks, diagnostics, methods, toos, and processes based on new evidence. We wi identify the organizationa features that support managers in contributing to cinica and corporate performance, buiding an enabing environment. Our third aim is to engage stakehoders as co-researchers through our coaborative research design. In addition to respondent vaidation, this approach wi deveop high impact channes for communicating the impications of findings. Our fina aim is to deveop the theory of managing, synthesizing current modes, theories of distributed eadership, and processua-contextua perspectives on change. Our coaborative research design invoves six acute trusts over six stages: (1) set up (research assistant, background information, iterature review, ethica approva), (2) management focus groups, (3) management survey concentrating on the themes of reaities, changes, and contributions, with 60 per cent of items common for a sites for comparison, and 40 per cent based on oca trust issues and priorities, (4) management briefings to check findings, expore impications, consider diffusion mechanisms, and identify cases for the next stage, (5) case studies of change foowing adverse incidents, and (6) pubication and knowedge transfer. We wi aso track changes in the management roe in one PCT, inked to one of the acute sites, exporing through interviews with a sma number of key informants (midde and senior managers) the impications for inter-organizationa reationships, and the impact on acute management roes. Research methods thus incude document anaysis, focus groups, sef-report survey questionnaires, interviews, and case studies of extreme change. Anaysis methods incude context profiing, content anaysis, statistica anaysis, visua mapping, event sequence anaysis, and ideas capture from briefing groups. Outcomes can be measured in terms of service impact. For patients and service users, this concerns management practices that wi improve quaity of care and cinica outcomes, and rapid changes foowing extreme events eading to improved patient safety. For midde and front ine managers, this means a better understanding of how the roe is evoving, new competency requirements, methods for infuencing cinica and organizationa outcomes, and techniques for managing extreme change. For senior managers, we wi provide guidance on management deveopment and support needs, and advice on deveoping an enabing context for the management impact on cinica, organizationa outcomes, and change. For poicy makers, this research wi deiver a mode of management work, expaining the demands and pressures, the new competencies required, the contributions to change and performance outcomes, and the impications of extending cinica engagement in management. Lay summary How do hospita managers hande the pressures and demands of a constanty changing heath service? What effect do managers have on the quaity of patient care and the outcomes of treatment? We know itte about the work experience and attitudes of hospita managers, but when things go wrong, this is the group which usuay takes the bame. Patient safety is a nationa priority, and we particuary want to find out how changes to working practices are managed after serious incidents. This can be a probem, as the advice of enquiries, in heath and esewhere, can often sit on the shef. This study wi buid on what we aready know about the reaities of midde and front ine management work and organizationa change. We wi coect the information we need using focus groups, a survey, and interviews which wi enabe us to deveop case studies of serious incidents and the changes to which they ead. We wi aso ask the midde and 118 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 front ine managers invoved in this study to hep us with the design of the survey, and with choosing exampes of serious incidents. As participating managers are among the main users of the findings from this project, we wi ask them to check our understanding of the data, and to hep us to deveop nove ways to communicate the impications, so that this work does have an impact on management practice. The study wi do this through advice on management support and deveopment based on a better understanding of how managers work and of the factors that are shaping their roes. We wi ook at how managers can contribute more effectivey to the quaity and outcomes of patient care as we as to overa hospita performance. And we wi deveop guideines for effectivey impementing changes to heathcare working practices. Detais of research proposa Introduction, aims and objectives This project wi address three reated sets of questions: 1. Reaities: What are the new pressures and demands facing midde and front ine managers in heathcare? What are the impications of these trends? How do managers cope with shifting priorities and expectations? 2. Changes: What roes do midde and front ine managers pay in impementing changes? How are changes arising from adverse events impemented, and how can this process be improved? 3. Contributions: How does management practice affect cinica and organizationa outcomes? What factors infuence the management contribution to performance? How can the components of an enabing environment for the management contribution be assembed and sustained? What we don't know The service has invested in senior management (Department of Heath, 2002). We know ess about the working ives of midde and front ine managers; the motives and rewards, the chaenges and tensions, how the job is changing, and new capabiities required. But when things go wrong, here is the group which often attracts most of the criticism. Managing reaities: we don't know whether or how today's nove pressures and demands are affecting the reaities of midde and front ine management work in acute settings, or the nature of the attributes and competencies required in these roes. But we do seem to understand the main components of traditiona genera management roes (Mintzberg, 1994). Managing change: we don't know why, foowing extreme or adverse events, inquiry recommendations sit on a shef, but are sometimes adopted rapidy. But impementing change is a key aspect of midde and front ine management work, and we do seem to understand many aspects of norma change in heathcare (Locock, 2001). Managing contribution: we don't know how midde and front ine managers infuence organizationa and cinica outcomes, through change impementation and other dimensions of the roe, or what woud reinforce that contribution. But we assume that management practice is fundamenta (Christian and Anderson, 2007). We wi thus foow the chain of evidence from management reaities, through change, to outcomes, focusing on midde and front ine managers in acute care. Midde and front ine refers to management posts beow trust board eve, incuding career managers, cinica staff in hybrid manageria roes, and medica staff who perform management and eadership functions (Department of Heath, 2008). This embraces ward sisters, consutants, genera managers, and cinica directors. Whie management in primary care is important, this is not a major theme in this project. PCT managers now focus on commissioning rather than deivering care, and SDO is funding separate research into commissioning. However, we are considering Queen's Printer and Controer of HMSO 2013. 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. 119

APPENDIX 1 a PCT case study, proposed by a participating acute trust, focusing on changes in the primary care management roe, impications for inter-organizationa reationships, and the impact on management in acute settings. Objective and aims Our overarching objective is to make a difference, contributing to the practice and theory of heathcare management to improve patient care and organizationa performance. Our first aim is to generate fresh evidence, concerning managing reaities, changes, and contributions. Our second aim is to deveop evidence-based guidance (toos, perspectives, frameworks, diagnostics, methods, approaches, processes), informing management deveopment, identifying factors jeopardizing and faciitating change, and enhancing the inks from management practice to organizationa and cinica outcomes. Our third aim is to engage stakehoders in the deveopment of actionabe knowedge, through our coaborative research design, disseminating impications by using our advisory board structure and participants to deveop innovative communication modes and channes. Our fourth aim is to contribute to the theory of managing, by synthesizing and buiding on current thinking with regard to modes of the management roe, theories of distributed eadership and change agency, and processua-contextua perspectives on organizationa change and service improvement. Managing reaities Midde and front ine managers face new pressures and demands; what are the impications? Managers, the textbook says, keep things running as they are, whie eaders drive change; administrators versus innovators. Managers at a eves in the NHS may be excused a cynica response to this distinction, having impemented a series of major changes affecting a aspects of the service cuture, structures, priorities, governance, working practices and more. The NHS Operating Framework for 2008/09 and the Next Stage Review continue the theme of transformation (Department of Heath 2007; 2008). Foowing Next Stage, medica training wi incude management and eadership skis as a matter of routine. How do heathcare managers professiona and cinica cope with a broad, diverse, and shifting agenda of competing priorities and expectations, and seria change generating reform fatigue (Leatherman and Sutherand, 2008)? How do midde and front ine managers cope with this chaenging and sometimes contradictory context? Managing changes There is a perception that heathcare is different, and that the management of change is probematic (Øvretveit and Asaksen, 1999). This has ed to a renewed emphasis on medica engagement in eadership and change (NHS Institute, 2008; Hamiton et a., 2008). Nevertheess, many of the goas of The NHS Pan have been achieved, switching priorities away from finance and waiting times to quaity of care, access, patient and pubic invovement, and patient safety (Department of Heath, 2007). Recent studies show that many radica changes are impemented, not by sma groups of senior managers and doctors, but by midde managers and other staff. With the emphasis on patient safety (a core standard; Heathcare Commission, 2007), we wi expore the processes of change which foow extreme, adverse, or sentine events, such as accidents, misconduct, and other serious untoward incidents. Considerabe efforts are often expended to earn the essons from such incidents, but those essons are not aways impemented (Donadson, 2000; Heathcare Commission, 2008). These issues have rarey been investigated from a change management perspective. We wi remedy this oversight, inked to a separate cross-sectora Cranfied project in this area. This is an area in which improved understanding wi significanty benefit practice and patients (Shorte et a., 2007). Managing contributions How does management practice infuence cinica and organizationa outcomes? Manageria effectiveness is a sippery concept, stakehoders have competing views (Michei and Neey, 2006), and assessing the impact of singe practices on specific resuts is probematic. Nevertheess, research suggests a systemic ink to outcomes (West et a., 2002; Boyne et a., 2006). Whie management competencies and practices are key, organizationa context is aso crucia, in determining receptiveness (Pettigrew et a., 1992), setting priorities and incentives, focusing attention and energy, and estabishing an environment that either enabes 120 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 or stifes service improvement. What does an enabing environment ook ike, and how can the components of this environment be assembed and sustained? Reevance to SDO ca for proposas Our project focuses on the reaities of management theme (iii); work ife, roes and behaviours, addressing priorities identified by Christian and Anderson (2007, p. 19) who concuded that, Management issues were seen as a fundamenta determinant of organizationa performance: in particuar the importance of different management practices; the competency of managers to fufi their roes; the abiity to ink in with front-ine staff; and invoving key figures in proposed changes. We wi expore reated themes, such as cinica manageria reationships, decision-making, and knowedge utiization (Rousseau, Manning and Denyer, 2008; David Denyer, is a member of the American evidence-based management coaborative estabished by Denise Rousseau). But a better understanding of managing reaities, changes, and contributions are where this research wi have the most significant impact on organizationa performance, and quaity and outcomes of patient care. A second intent of this ca for proposas is to promote exchange between academic and practitioner communities. Our project engages participating managers throughout the research process, from deveoping this proposa, through advising on the coection and interpretation of data, to deveoping impications for practice, and disseminating findings. Background; NHS context and reevant iterature Of the 1.3 miion empoyees in the NHS in Engand, there are approximatey 36,500 managers, ess than 3 per cent of the tota (The Information Centre, 2007). That probaby underestimates the number of staff who as part of their roe perform management functions. And that percentage understates the significance of management contributions to performance. The desire to engage medica staff in management and eadership dates from the 1980s, and has achieved new urgency in current proposas, such as the medica eadership competency framework approved by the Academy of Medica Roya Coeges (NHS Institute, 2008; Hamiton et a., 2008). In the context of the theoretica underpinning expained shorty, it is interesting to note that John Cark (Cark et a., 2008, p. 33), director of the Enhancing Engagement in Medica Leadership project observes 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. It is a set of behaviours that shoud appy to a rather than a few. Athough the Next Stage Review promises no new targets, the change agenda is sustained. Lord Darzi focuses management attention on acceerating the pace of change with regard to quaity of care (inked to funding), patient choice, personaized budgets and care pans, and integrated care, compemented by cinica and board eadership programmes (Department of Heath, 2008). The Operating Framework for 2008/09, noting a shift in emphasis away from finance and waiting times, decares an ambitious new chapter in the transformation of the NHS, focusing on other issues incuding patient safety, access, better heath and reduced inequaities, improving the patient experience and staff satisfaction, and enhanced emergency preparedness; not a recipe for stabiity (Department of Heath, 2007). These aspirations wi be achieved by empowering oca management and staff to deiver with ess centra direction. The Operating Framework aso makes cear (p. 32) that the status of Foundation Trust is no onger an aspiration, but an expectation for a. The governance arrangements of Foundation Trusts, particuary with service ine reporting, mean that trusts, and their cinica services, run ike businesses. Pans and decisions are now commony couched in commercia discourse; business units, customers, competitors, marketing ( promotion of services ), cost aocations, profitabiity, portfoio anaysis, mergers and acquisitions, business deveopment (e.g., Shepherd, 2008). This refects vaues different from those that have inspired a pubicy Queen's Printer and Controer of HMSO 2013. 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. 121

APPENDIX 1 funded heathcare system for the past 60 years. Our anecdota evidence indicates that managers generay wecome these deveopments, but that many cinica staff remain sceptica. There is evidence to suggest that these changes are creating new tensions (Sambrook, 2005). It is in this dynamic context of the ongoing acceerating transformation of heathcare that this study is positioned. Reaities Broady, we think we understand what managers do; roes (Mintzberg, 1973; 1994), reaities (Stewart, 1997), rewards and pains (Watson, 1994), how they spend their time (Kotter, 1999). But is that knowedge reevant to heathcare management today? Previous research into management roes is mainy ethnographic, using observationa methods. Haes (1999) criticizes work which describes management without a theory of managing. Our aim is to understand the inks between the reaities and the contributions of management work. This wi take the form of a mutieve perspective synthesizing three theoretica enses (Watson, 1997). First, frameworks such as Mintzberg (1994) are a usefu starting point, highighting the interaction between vaues, competencies and stye, roe purpose, managing information, peope and action, and the wider context. This mode assumes a manager responsibe for a singe unit, a situation that does not aways appy in the coaborative, process-driven, network organizationa forms common in heathcare, where managing across interna and externa boundaries is increasingy important. This mode is sient concerning the inks from management practices to outcomes; the we rounded manager is presumaby effective. Second, theories of distributed eadership (Gronn, 2002) draw attention to the fuid contributions to change at a eves (Baiey and Burr, 2005; Buchanan et a., 2007a). Third, process expanations consider how factors at different eves of anaysis interact over time to shape outcomes (Langey, 2009). This perspective views context not as a neutra stage on which action unfods, but as shaping conditions, events, interactions, and outcomes by enabing, constraining, and predisposing (Fitzgerad et a., 2002). Changes Recent studies undermine the distinction between eaders who drive change and managers who maintain order, portraying midde management roes in strategy, and in change by steath and under the radar (Foyd and Woodridge, 1996; Huy, 2002; Badaracco, 2002). The deveopment of distributed change eadership, based on the spontaneous concertive action of staff at a eves, is evident in heathcare (Brooks, 1996; Lüscher and Lewis, 2008). From a recent SDO project, Buchanan et a. (2007b) describe a distributed approach to service improvement in the treatment of prostate cancer invoving arge numbers of staff across the cancer network organizations. Contradictory anecdota evidence suggests that midde managers foow directions, and have itte input into the design of change, focusing on the immediate and the tactica, but there is no robust evidence concerning midde and front ine management experience and perceptions. Impementing change foowing extreme, adverse or sentine events, such as accidents, misconduct, and other serious incidents, is often probematic. We don't know why this is so, athough this affects patient safety. Consequenty, we wi focus on these events, rather than deveop yet another n-step guide to norma change (Coins, 1998). Donadson (2000) recognized the gap between passive earning (estabishing the essons) and active earning (embedding new practices). But in a recent report, he observes that the pace of change has been too sow and that we need to redoube our efforts to impement systems and interventions that activey and continuousy reduce risk to patients (Department of Heath, 2006, p. 4). Our preiminary working definition of an extreme event is an incident that suggests the need for significant organizationa changes in order to prevent or to reduce the probabiity of a recurrence. When extreme events occur, the focus tends to ie with estabishing cause, attributing bame, and remedy. Once recommendations from an enquiry are pubished, attention fades. Research has mirrored this profie of concern. There are studies of the incubation phase, (Turner and Pidgeon, 1997), the causes of norma accidents (Perrow, 1999; Vaughan, 1999), the critica period (Stein, 2004), sensemaking in crises (Weick, 1993), crisis management (Lagadec, 1997; Laonde, 2007), high reiabiity organizations (Weick and Roberts, 2003), and the roe of pubic inquiries (Brown, 2000; 2003). The impementation phase has attracted ess attention, and studies of extreme events from a change management perspective are acking (athough much can be earned from outiers; Pettigrew, 1990). Research on avoiding wrong site surgery is instructive, Rogers et a. (2004) noting that guideines are inconsistenty impemented because of the faiure to account for the 122 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 compex operating theatre environment. Linked to a separatey funded cross-sectora study with overapping project team membership, we wi expore the conditions that respectivey bock and promote active earning and change in such contexts. Contributions Buiding on the concept of the receptive context for change (Pettigrew et a., 2002), we wi identify the custers of factors that respectivey stife and strengthen the contributions of midde and front ine managers to cinica and organizationa outcomes. We wi identify the features of an enabing environment, and expore how these differ within and across acute care settings. Identifying the impact of management practices and changes on organizationa performance is probematic (Ies and Sutherand, 2001). This is due to the systemic nature of the inks between actions and outcomes (West et a., 2002), to the mutipicity of stakehoders, and to the sociay constructed nature of effectiveness. Understanding these inks requires a process perspective, in contrast with traditiona variance expanations (Mohr, 1982; Langey 1999 and 2009; Van de Ven and Pooe, 2002; Buchanan and Dawson, 2007). Process expanations demonstrate how antecedents ead, in particuar contexts, to outcomes over time. The concept of conjunctura causaity invoves identifying the custers, combinations, or configurations of factors that expain the consequences of interest (Armenakis and Bedeian, 1999; Godstone, 2003; Waker et a., 2007; Fitzgerad and Buchanan, 2007). A recent review of research concerning contributions to service improvement through medica engagement in management reveaed itte positive impact, but demonstrated how ack of such engagement is probematic (Ham and Dickinson, 2007). Pan of investigation Research design Coaborative research designs, athough not without probems, have been shown to be effective in transating research into practice in heathcare (Denis and Lomas, 2003), and aow for oca taioring of data coection. User engagement contributes to the deveopment and dissemination of findings, and to buiding research capacity among those invoved. This design combines quantitative and rich idiographic data, enabing within-organization, cross-organization, cross-occupation and other comparisons. Outputs wi be generated at each stage, not just at the end of the project. This is a six-stage muti-methods coaborative design invoving six hospitas and one primary care trust. The acute sites dispay geographica spread, incuding Foundation and non-foundation Trusts. We may add trusts with wider variance in financia chaenge, popuation characteristics, and oca competition, for the survey described in the methods section. Advisory groups We require a sounding board invoving concerned and passionate individuas who wi earn with us whie contributing their ideas and insights. So, we wi estabish a two-tier advisory group. Tier one incudes four heathcare managers and two independent academics, meeting quartery. Tier two is a virtua group, with 20 managers and cinica staff drawn from our nationa, regiona, and oca networks, and with whom contact wi be maintained by teephone, e-mai, WebEx, and our project website. These two groups wi advise on project methods and focus, access to stakehoder networks, interpretation of findings, appications, and dissemination. The combination of Operating Framework priorities, SHA visions, Loca Area Agreements, Next Stage Review, and other nationa initiatives impies that management structures and roes in pace as this research unfods may differ from configurations at the proposa stage. Management practice in heathcare is a moving target, and our sounding board wi ensure that this study sits at the cutting edge of practice and theory. Research methods This is a muti-methods coaborative project using oca participation, focus groups, surveys, documentation, performance data, case exempars based on documentation and interviews, and management briefings. We wi engage participants as co-researchers, in survey questionnaire design, case seection, data anaysis and Queen's Printer and Controer of HMSO 2013. 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. 123

APPENDIX 1 interpretation, exporing impications for management practice, and deveoping innovative methods for disseminating findings. Stage 1a (3 months) pre-research administration activity The first three months of this project wi invove: i. obtaining muti-centre and trust ethica approvas we wi seek approva for the study as a whoe, then submit the questionnaire design as an amendment; ii. recruiting, orienting, and equipping our research assistant; iii. conducting a systematic review of the iterature on midde and front ine heathcare management, the management of extreme change in heathcare, and modes of management contributions to heathcare organization outcomes; iv. recruiting members of our advisory groups; v. estabishing inks with other research teams working on simiar questions; vi. designing and estabishing the project website. Stage 1b (three months) site briefing and set-up processes The second three months of this project wi invove: i. the coection of background information on our research sites through internet downoads and informa meetings; ii. acute trust iaison and briefing meetings with senior management to estabish working contacts aong with administrative and ogistica arrangements; iii. setting up the primary care case study, identifying up to five key informants (midde and senior managers), coating background documentation, arranging site visits (four to six over two and a haf years), inking with other SDO research in this domain. Stage 2 (6 months) Management focus groups We wi run three or four focus groups at each of the six acute trusts. Aiming for attendance of around 8 at each focus group meeting, this procedure wi invove between 150 and 200 managers who wi hep us to understand new and emerging themes, pressures, trends and deveopments affecting midde and front ine management in genera, and in particuar with regard to oca management needs, issues, and priorities. The findings from these focus groups, at each site, in aggregate, and considering cross-site comparisons, wi thus inform the subsequent survey design, and wi constitute data in their own right, on the changing nature of midde and front ine management work. Stage 3 (9 months) The 60-40 Survey This survey questionnaire wi generate evidence on the nature of new and emerging management pressures and demands, and the impications for management practice, for management deveopment and support, and for a theory of managing. Capturing experiences and attitudes, we wi survey the midde and front ine management popuations (around 1,500 tota) in our participating acute trusts. We wi use a 60-40 design, in which approximatey 60 per cent of survey items wi be common to a sites, for comparison and benchmarking purposes, and 40 per cent wi be taiored to oca priorities foowing the advice of the management focus groups. As we as the content, the percentages of common and taiored items are ikey to vary between sites, and these variations wi in turn provide further usefu insights. The time aocated to this stage of the project refects the workoad invoved in administering the survey, and then coecting, coding, and anaysing the data. Subject to participant input and oca taioring, indicative themes are ikey to incude: Biodata survey responses wi be anonymous and the data confidentia standard biodata to permit a range of within-sampe comparisons 124 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 background; heathcare, other pubic sector, commercia, cinica, armed forces and current roe; manageria, hybrid, cinica with management duties Managing reaities vaues, attitudes, motives, priorities new pressures, demands, patterns of activity, and fresh emphases shaping the work changing persona attributes and competency requirements the management support and deveopment impications of current trends Managing changes effect of professiona barriers and mutidiscipinary teams on service improvement management attitudes to innovation, growth, and risk what factors bock effective impementation of service improvement change issues arising in impementing the essons from extreme events Managing contributions is there a medica manageria divide over what constitutes performance which practices, methods, perspectives make a difference what barriers must be removed to strengthen the impact of management practices does an audit and compiance context stife innovation These themes wi be eaborated through participant coaboration in focus groups, to ensure that the survey addresses oca needs and priorities as we as the overa research objectives. Stage 4 (3 months) Management briefings It is important that research participants have an eary opportunity to assess the findings and their impications. At this stage, findings wi be presented to vounteer management focus groups at each site, with five objectives. First, for respondent vaidation. Second, to check interpretations. Third, to deveop practica impications. Fourth, to expore innovative modes of dissemination. Fifth, to identify exempars case studies for stage 5. Stage 5 (6 months) Managing extreme events These case exampes wi improve our understanding of change processes foowing adverse or extreme incidents, and hep deveop practica diagnostics and frameworks. We wi ask briefing groups to identify six incidents, nominay one in each acute trust. The main case seection criterion concerns opportunity to earn about the conditions in which changes foowing an extreme incident are either straightforward, or probematic, respectivey. Through interviews and documentation, we wi identify factors contributing to the outcomes. Athough a sma sampe, we wi deveop moderatum generaizations (Wiiams, 2000), and contribute to theory through anaytica refinement (Tsoukas, 2009). Recognizing the sensitivities and emotions potentiay surrounding such events, discussions with potentia study sites suggest that research in this area is ess probematic than might appear, for severa reasons. First, significant reevant information is often aready in the pubic domain. Second, our focus ies with the subsequent management of change, and not with conducting fresh investigations. Third, the desire for individua and organizationa earning is often strong and unmet. Fourth, those who have been invoved often wecome an opportunity confidentiay and anonymousy to share their thoughts and experiences. Fifth, we wi incude successfu exampes of change foowing extreme incidents, as equay vauabe earning opportunities. Finay, events may have occurred in the past, aowing emotions and sensitivities to subside. Stage 6 (6 months) pubication and knowedge transfer We wi engage our advisory groups and the management participants in this project the end users of the resuts in a series of informa exchanges and where possibe face to face meetings, to hep deveop Queen's Printer and Controer of HMSO 2013. 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. 125

APPENDIX 1 innovative modes of dissemination (beyond professiona journas, academic artices, and engthy reports). We recognize the need to deveop high impact, readiy accessibe modes of communication, which retain the integrity, and where appropriate the compexity, of the issues at stake and the impications for practice. The main anaytica approaches and techniques that we wi depoy at each stage, what we wi be ooking for, and the anticipated contributions to each of the project's three main themes reaities, changes, and contributions are summarized in Tabe 1. In addition to this structured approach, we wi be ooking for the surprising, the unexpected, the outiers in these data streams, and we wi be considering what fresh insights practica and theoretica these are ikey to revea. Data coection and management procedures This section expains the project data coection and handing arrangements, expaining how ethica issues arising from this study wi be addressed. TABLE 1 Anaytica strategies and outcomes Stage, ink to themes Anaysis, what wi this te us 1. Set-up Context profiing, of participating trusts based on background documentation, key organizationa and environmenta factors Managing reaities Primary care case Outcomes: identify oca priorities, dimensions of within- and cross-site variations, factors potentiay shaping management reaities Thematic case report documenting two-year period Outcomes: changes in management roe in primary care, impications for inter-organizationa reationships, impact on acute management 2. Focus groups Content anaysis, of discussion and key themes Managing reaities Managing change Outcomes: identify recurring patterns of emerging themes, pressures, trends, emphases, and deveopments affecting midde and front ine management; deeper understanding of oca needs and priorities, identify idiosyncratic, unexpected, outier themes 3. 60-40 survey Statistica anaysis, frequency distributions and crosstabs (ordina and nomina data); coding and content anaysis of open responses Managing reaities Managing change Managing contribution Outcomes: sampe characteristics, motives and vaues, incidence and experience of new chaenges and trends, factors and practices impacting effectiveness, components of enabing and disabing environments for management work, changing patterns of management activity, comparisons of attitudes and experience controing for age, experience, gender, current roe, background, service area and/or function, cross-site comparisons, cross-occupationa (e.g., medica-manageria) perceptions and reationships, site-specific findings, unexpected outier resuts 4. Briefing groups Content anaysis, of discussion and key themes Managing contribution Outcomes: respondent vaidation, practitioner check on anaysis and interpretations, expore management impications, capture dissemination ideas, identify case exempars for next stage 5. Extreme events Visua mapping and event sequence anaysis, of incident narratives Managing change Managing contribution Outcomes: identify recurring success and probem patterns in extreme change processes, deveopment of conjunctura expanations, contingency management framework based on cross-case comparisons of incidents and foowing contexts 6. Knowedge transfer Ideas capture Managing contribution Outcomes: carify and strengthen impications for management practice, deveop high impact communications methods, range of pubications, briefing seminars and documents, management deveopment and support programmes 126 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Informed consent, confidentiaity, and right to withdraw The methods used for data coection in this study invove a combination of focus groups, sef-report survey, and quaitative case studies based on interviews and document anaysis. These are standard organizationa research methods, which are appropriate to the research aims, organizationa context, and participants. The participants are a midde and front ine hospita managers, with a sma number of senior managers serving as gatekeepers to the study in their respective organizations. There is no direct or indirect patient invovement. The primary ethica issues thus concern informed consent, anonymity and confidentiaity, and the right to withdraw from the study at any time without question. Informed consent wi be addressed in two ways. First, a potentia participants wi be given detaied participant information sheets. Given the duration of the project, and the different methods that wi be used, separate information sheets wi be distributed prior to the different stages of the project, expaining both the aims and methods of the project as a whoe, and the specific purpose and nature of the focus groups, survey, briefing groups, and case interviews respectivey (appended). Where possibe and appropriate, distribution of information sheets wi be prefaced by a question-and-answer briefing, organized by the management gatekeepers at each site, and deivered by a member of the research team, expaining the aims and methods of the study, guaranteeing anonymity and confidentiaity, and expaining the right to withdraw. Second, participation in this study is vountary, at the discretion of individua managers. The time that wi eapse between receipt of the participant information and the scheduing of the corresponding data coection wi be a minimum of one week. Individuas taking part in focus and briefing groups and in interviews in the course of this project wi sign consent forms; appropriatey amended versions of these consent forms wi be used (appended). Signed consent wi be obtained by the research team member on the day of each meeting, prior to which potentia participants wi have aready seen the project participant information sheet. The first question that members of the research team wi aways ask wi concern further questions about the project which participants may have before data coection begins. As consent forms wi discose individua identities, these wi be stored in a ocked drawer in an administrative office which is permanenty staffed during working hours (two staff members take breaks in turn), and which is ocked outside working hours (and is aso ocked if for some reason both members of staff need to be absent at the same time). Consent forms wi be destroyed at the end of the project. Anonymity and confidentiaity wi be guaranteed in two ways. First, data wi be reported in aggregate. The organizations invoved in the study wi be give pseudonyms ( Loamshire NHS Trust ) uness permission is granted in writing to use the organization's rea name. Where verbatim quotes from individuas are used to iustrate findings, these wi be anonymised ( a manager said ) and identity cues wi be omitted. Second, project data wi be stored on password-protected Cranfied University computers, and individua comments wi not be stored in eectronic fies with attributabe names. Transcripts of group meetings and interviews, and fies containing other sensitive information, wi be stored in a password-secured project foder on the Schoo of Management server, which itsef can ony be accessed (ocay or remotey) with a separate username and password. There wi therefore be no need for research team members to exchange fies by e-mai or to store fies on usb memory, both of which pose potentia data security risks. Cranfied Schoo of Management carries professiona indemnity insurance for research staff, giving participants in this study a ega remedy shoud breach of confidence occur. The right to withdraw is expained ceary and unambiguousy in the participant information sheets, and decisions to withdraw wi be respected without question. Participants time commitment Focus group meetings wi each ast around one hour. Sef-report survey questionnaire competion wi take approximatey thirty minutes. Briefing group meetings wi each ast around one hour. Case study interviews wi each ast around one hour; depending on how each case study deveops, we may ask a sma number of participants for a foow-up interview (conducted under the same conditions as the first Queen's Printer and Controer of HMSO 2013. 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. 127

APPENDIX 1 interview), again asting for up to an hour. Interviews for the primary care study wi ast from haf an hour to one hour each. A sma number of participants may be invoved in focus groups, survey, briefing groups, and case study interviews; for those participants, the tota time commitment to this project over three years woud be approximatey three and a haf hours (four and a haf hours if a re-interview were requested and consent given). For most participants, however, participation in this study is ikey to invove one procedure ony, asting from haf an hour to one hour. For the primary care study, the time commitments of interviewees wi tota six hours over three years. Sensitive topics As this project wi expore a range of different aspects of midde and front ine management roes, it is possibe that some participants may find themseves being sharing information about work experiences that they may have found difficut and/or distressing. Such discosure, which wi be vountary, coud nevertheess ead to persona discomfort. This might incude, for exampe, management pans and actions that were not successfu, or serious incidents affecting staff and/or patients where the participant was invoved in some manner. This possibiity wi be addressed in the first instance through paragraphs in the participant information sheets for focus and briefing groups and case interviews indicating that this situation coud arise, and that participants shoud take this into account when deciding whether or not to contribute to this project. Shoud this situation then arise during a group discussion or interview, the researcher present wi terminate the conversation immediatey. If the participant woud find it hepfu, the research team member wi then offer the participant an opportunity to discuss the matter further, in a private debriefing, off the record. Shoud such a situation arise, the associated information wi not be recorded, wi not be discussed with other members of the research team, and wi not be added to the data stream for this project. Participant identification We wi rey on senior management gatekeepers to identify the midde and front ine management popuation at each acute trust, to communicate the project information to them, and to invite them to consider attending our focus group meetings in stage 2, to take part in the survey in stage 3, to attend the briefing sessions in stage 4, and to contact us for interview in stage 5. As the criterion for incusion in this study concerns hoding a midde or front ine management position in an acute trust, potentia participants wi be screened by job tite, and where necessary by job description (job tites do not aways ceary indicate whether or not a particuar roe is a manageria one, or has a manageria component). There is, however, no requirement for members of the research team to have sight of any persona records of the staff invoved. For the primary care case study, we wi again rey on a senior management gatekeeper to identify potentia informants, to communicate the project to them, and to ask them to consider contacting the research team either for interview, and/or to discuss the project further before making a fina decision with regard to participation. Members of the research team wi not have sight of any persona records reating to any trust management staff, the identification of participants and direct communication with potentia participants being faciitated by a senior management gatekeeper nominated by the chief executive in each participating trust. Where it may be necessary to inspect a job description, a generic description for a post of that kind wi suffice, and there wi be no need for members of the research team to see job descriptions for specific individuas. For the purposes of this study, ony job tites wi be used as identifiers for data storage and anaysis purposes. For stage 5 of the project, interviewees wi be identified on a key informant basis depending on their roes in reation to the incidents chosen for study. As these incidents wi be identified by participants in briefing groups in stage 4, these key informants cannot be identified unti the case incidents have been determined. We anticipate that some key informants wi be briefing group participants who wi thus be sef-nominating, but whose informed consent to participate in this stage of the project wi sti be sought. Contacting participants Participants at each participating trust wi first be informed of this study through a genera interna maiing to a potentia participants from the trust chief executive, or from her or his nominee. This wi be accompanied 128 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 by the focus group participant information sheet describing the aims and methods of the study, and the nature of the participation required at this stage. This information sheet expains our procedures for guaranteeing anonymity and confidentiaity, and aso expains the right to withdraw from the study at any time without question. The information sheet carries contact information for the research team members who can be contacted directy by potentia participants who may have questions or concerns about the study. Foowing circuation of the information sheet, focus group meetings wi be schedued in each participating trust, and midde and front ine managers wi be invited to attend these, again through an interna maiing circuated by the chief executive's nominee. Simiar centra maiing procedures wi then be depoyed at subsequent stages of the project for the purposes of the sef-report survey and briefing groups. With regard to the case study incidents that wi form the focus of stage 5 of this project, these wi be nominated by participants in the briefing group discussions during stage 4. We wi therefore aso ask participants to identify the coeagues who are ikey to be key informants in reation to those incidents which in many cases wi probaby incude themseves and to speak to them on behaf of the research team, inviting them to approach us for interview. Given the project timescae, it may be appropriate at the start of this stage to circuate the project information sheet again to potentia informants. For stage 5 we wi ask briefing group participants who suggest particuar incidents for further study, or the appropriate senior management gatekeeper at each site, to pass the reevant participant information sheet to potentia key informants, asking them to contact the designated member of the research team if they woud be wiing to share their experience of that incident. Shoud key informants in reation to a nominated incident not be forthcoming, we wi not pursue that case further, but instead seek identify a substitute incident. (Experience in other sectors with simiar issues suggests that we are ikey to be presented with more such incidents than it wi be possibe to foow up given the time and resources avaiabe to the project.) Data storage and retention Survey and interview data wi be stored eectronicay in appropriate computer fies. A Cranfied computers, PCs and aptops, are configured with password-protected access. Data wi be stored on the Schoo of Management server which can ony be accessed by users with assigned usernames and passwords, and in a project foder that can ony be accessed with a further password. This procedure restricts access to project data to member of the research team, and obviates the need to exchange fies by e-mai or to store fies on usb memory. No data from this project wi be stored on NHS computers or on computers beonging to any other organizations. We wi use digita recorders to record interviews where permission is granted and digita fies (which can take up considerabe disk storage space) wi be deeted foowing transcription. Fies recording focus group discussions and interview transcripts wi be abeed anonymousy to avoid discosing identities. Direct quotations from participants may be used in a fuy anonymised manner in reports and pubications, and this usage is expained in the project participant information sheet. We wi not, without permission, use the actua name of any of the Trusts invoved in this study; given the research aims and objectives, this wi not be necessary. For reporting purposes, therefore, trusts wi be aocated pseudonyms (e.g., Norwood NHS Trust, Grange NHS Trust ). Senior managers who have acted as gatekeepers for this project wi be asked to check reports prior to submission for pubication in order to ensure that identity cues have been omitted. Ony members of the research team wi have access to participant data reating to this study. These data wi reate ony to what participants have said in conversation (focus and briefing groups and interviews) and to sef-report survey responses, and wi not incude any other persona data beyond the basic biodata requested in the survey instrument. Data wi be anaysed by members of the research team, either on the Cranfied campus, or in researchers' home offices. Computer fies incuding transcripts of group discussions and interviews wi contain no persona identifiers. This study wi generate a significant amount of quantitative and quaitative data, which can be anaysed and written up in a range of different ways, for different purposes. In order to maximize the contribution of this study, to theory and to NHS management practice, our aim is to disseminate the findings and their Queen's Printer and Controer of HMSO 2013. 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. 129

APPENDIX 1 impications widey, in a range of traditiona and innovative styes (pubications and teaching materias, for exampe). That process is unikey to be competed within tweve months foowing the officia end-date of the project. However, there wi be no need to store data for more than five years as we expect that our aims in this regard wi have been accompished by then. Data wi continue to be stored after the project in the same manner as during the project, on password protected Cranfied University computers to which ony members of the research team have access. If the data custodian, Professor David Buchanan, were to eave the institution during this period, this responsibiity wi pass to another member of the research team, in the first instance to Dr Catherine Baiey, then if necessary to other team members in aphabetica sequence. Benefits to the NHS For patients and service users, athough not invoved directy in project fiedwork, this research wi deiver: management practices and organizationa features that have been demonstrated to contribute to improved quaity of care and cinica outcomes; rapid changes to working practices foowing extreme events, thus eading to improved patient safety. For midde and front ine managers, this research wi deiver: knowedge of how midde and front ine management work is evoving, and why; new competency requirements, and how these are acquired and can be best supported; new practices, toos, diagnostics, and frameworks for infuencing cinica outcomes, care quaity, and organizationa performance; approaches and techniques for managing both extreme and norma organizationa change. For senior managers, this research wi deiver new information on management deveopment priorities and support needs, and a practica guide to the construction and maintenance of an enabing context for maximizing the impact of management practices on cinica, care-reated, organizationa, and change-reated outcomes. For poicy makers, this research wi deiver a mode of heathcare management work, expaining the demands and pressures which these roes generate, the competencies required, the contributions of management practices to change and performance outcomes, and the impications for extending cinica engagement in management and eadership roes. This project wi thus deiver fresh evidence about the reaities of midde and front ine management work, new perspectives on the impementation of change in atypica circumstances, and a better understanding of the effects of management practices. Whie evidence, perspectives, and understanding are intangibe outcomes, they are nevertheess vauabe to the extent that they redirect attention and energy, shape our understanding of probems and the settings in which they arise, and hep to guide practica action. The invovement of stakehoders Our research design has the advantage of invoving significant numbers of individuas with experience of and commitment to the service. Stakehoders wi have mutipe opportunities to contribute insights and to chaenge. This project has severa nationa, regiona, and oca stakehoders incuding poicy makers, managers, cinica staff, and patients. These groups are not remote entities to be considered when the study is over. On the contrary, one roe of our virtua advisory group is to hep us to capture the views of those groups from the start. 130 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Cranfied's mission is to improve management practice through research that generates near to market actionabe knowedge. Our coaborative design, advisory groups, the invovement of management participants, focus and briefing groups, and dissemination mechanisms, are intended to ensure continuing stakehoder invovement, particuary in the co-production of impications for practice, and innovative ideas for dissemination. Dissemination pans Researcher: In what form woud you ike to see our findings presented? Chief executive: Not another report. Our staged and coaborative research design means that outputs wi deveop throughout the project, and data streams wi be utimatey combined into a series of pubications, incuding academic journas and a book. Our fina report wi be compemented by briefs summarizing practica guidance, and we wi pubish in practitioner journas. We wi aso use Cranfied open and customized programmes, and our Pubic Sector Performance Roundtabe. The project wi feature on our Schoo website, and WebEx wi be used as an interactive dissemination too. We wi aso contribute to practitioner workshops and conferences. But those are a reativey conventiona outcomes. We are sensitive to the need to deveop high impact communication and dissemination media and channes for this project. To hep us to deveop more innovative methods for disseminating findings, propeing the research-into-practice process, we wi be driven by ideas from our project advisory and management briefing groups. We wi be seeking their ideas in this respect throughout the project, and not just towards the end. Project timetabe* This project wi run over 42 months, from 1 January 2009 to 30 June 2012: Stage 1a Pre-research administration activity: January to October 2009 Stage 1b Site briefing and set-up processes: Apri to December 2009 Stage 2 Management focus groups: January 2010 to December 2010 Stage 3 The 60 40 survey: January to September 2011 Stage 4 Management briefings: June to December 2011 Stage 5 Managing extreme events: January 2010 to December 2011 Stage 6 Pubication and dissemination: ongoing * These timings are approximate, affected by deays generated by ethica approvas process, and pressures on service managers Interim reports We wi submit interim reports during the first month foowing the competion of each stage of the project in Juy 2009, January 2010, October 2010, January 2011, Juy 2011, and January 2012. These reports wi summarize progress, key findings, theoretica deveopments, practica impications, probems arising and how these wi be addressed, and wi highight any unusua, unanticipated, and particuary significant issues and outcomes. Queen's Printer and Controer of HMSO 2013. 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. 131

APPENDIX 1 References Armenakis, A.A. and Bedeian, A.G. (1999) Organizationa change: a review of theory and research in the 1990s, Journa of Management, 25(3): 293 315. Badaracco, J.L. (2002) Leading Quiety: An Unorthodox Guide to Doing the Right Thing. Boston, MA: Harvard Business Schoo Press. Baiey, C. and Burr, J. (2005) Luck, Legacy, or Leadership: The Contribution of Leadership to Sustained Organizationa Success in NHS Trusts. Cranfied: The NHS Leadership Centre and Cranfied Schoo of Management. Boyne, G.A., Meier, K.J., O'Tooe, L.J, and Waker, R.M. (eds) (2006) Pubic Service Performance: Perspectives on Measurement and Management. Cambridge: Cambridge University Press. Brooks, I. (1996) Leadership of a cutura change process, Leadership and Organization Deveopment Journa, 17(5): 31 7. Brown, A.D. (2000) Making sense of inquiry sensemaking, Journa of Management Studies, 37(1): 45 75. Brown, A.D. (2003) Authoritative sensemaking in a pubic inquiry report, Organization Studies, 25(1):95 112. Buchanan, D.A. and Dawson, P. (2007) Discourse and audience: organizationa change as muti-story process, Journa of Management Studies, 44(5): 669 86. Buchanan, D.A., Cadwe, R., Meyer, J., Storey, J. and Wainwright, C. (2007a) Leadership transmission: a mudded metaphor? Journa of Heath Organization and Management, 21(3): 246 58. Buchanan, D.A., Addicott, R., Fitzgerad, L., Ferie, E. and Baeza, J. (2007b) Nobody in charge: distributed change agency in heathcare, Human Reations, 60(7): 1065 90. Christian, S. and Anderson, S. (2007) Review of Research Needs and Priorities 2007. London: NHS Nationa Institute for Heath Research. Cark, J., Spurgeon, P. and Dent, J. (2008) Surrender to progress, Heath Service Journa, 14 February, pp. 32 3 Coins, D. (1998) Organizationa Change: Socioogica Perspectives. London: Routedge. Denis, J.-L. and Lomas, J. (2003) Convergent evoution: the academic and poicy roots of coaborative research, Journa of Heath Services Research and Poicy, 8(2): 1 5. Department of Heath (2002) NHS Leadership Quaities Framework. London: NHS Modernisation Agency Leadership Centre. Department of Heath (2006) Safety First: A Report for Patients, Cinicians and Heathcare Managers. London: Department of Heath. Department of Heath (2007) The Operating Framework for the NHS in Engand 2008/09. London: Department of Heath. Department of Heath (2008) High Quaity Care For A: NHS Next Stage Review Fina Report. London: Department of Heath, cmnd 7432. Donadson, L. (2000) An Organization With a Memory. London: Department of Heath/The Stationery Office. Fitzgerad, L. and Buchanan, D.A. (2007) The sustainabiity and spread story: theoretica deveopments, in David A. Buchanan, Louise Fitzgerad and Diane Ketey (eds), The Sustainabiity and Spread of Organizationa Change: Modernizing Heathcare. Abingdon, Oxon: Routedge, 227 248. 132 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Fitzgerad, L., Ferie, E., Wood, M. and Hawkins, C. (2002) Interocking interactions, the diffusion of innovations in heathcare, Human Reations, 55(12): 1429 49. Foyd, S.W. and Woodridge, B.J. (1996) The Strategic Midde Manager. San Francisco: Jossey-Bass. Godstone, J.A. (2003) Comparative historica anaysis and knowedge accumuation in the study of revoutions, in James Mahoney and Dietrich Rueschemeyer (eds), Comparative Historica Anaysis in the Socia Sciences. Cambridge: Cambridge University Press. pp. 41 90. Gronn, P. (2002) Distributed eadership as a unit of anaysis, Leadership Quartery, 13(4): 423 51. Haes, C. (1999) Why do managers to what they do?: reconciing evidence and theory in accounts of manageria work, British Journa of Management, 10(4): 335 50. Ham, C. and Dickinson, H. (2007) Engaging Doctors in Leadership: A Review of the Literature. Coventry: The NHS Institute for Innovation and Improvement. Hamiton, P., Spurgeon, P., Cark, J., Dent, J. and Armit, K. (2008) Engaging Doctors: Can Doctors Infuence Organisationa Performance. London: Academy of Medica Roya Coeges and NHS Institute for Innovation and Improvement. Heathcare Commission (2007) Criteria for Assessing Core Standards in 2007/2008: Acute Trusts. London: Commission for Heath Audit and Inspection. Heathcare Commission (2008) Learning From Investigations. London: Commission for Heath Audit and Inspection. Huy, Q.N. (2002) Emotiona baancing of organizationa continuity and radica change: the contribution of midde managers, Administrative Science Quartery, 47(1): 31 69. Ies, V. and Sutherand, K. (2001) Organizationa Change: A Review for Heath Care Managers, Professionas and Researchers. London: Nationa Co-ordinating Centre for NHS Service Deivery and Organization Research and Deveopment. Kotter, J.P. (1999) What effective genera managers reay do, Harvard Business Review, 77(2): 145 59. Lagadec, P. (1997) Learning processes for crisis management in compex organizations, Journa of Contingencies & Crisis Management, 5(1): 24 31. Laonde, C. (2007) The potentia contribution of the fied of organizationa deveopment to crisis management, Journa of Contingencies & Crisis Management, 15(2): 95 104. Leatherman, S. and Sutherand, K. (2008) The Quest for Quaity in the NHS: A Mid-Term Evauation of the Ten-Year Quaity Agenda. London: Nuffied Trust. Langey, A. (2009) Studying processes in and around organizations, in David A. Buchanan and Aan Bryman (eds), The Sage Handbook of Organizationa Research Methods. London: Sage Pubications (forthcoming). Lüscher, L.S. and Lewis, M.W. (2008) Organizationa change and manageria sensemaking: working through paradox, Academy of Management Journa, 51(2): 221 40. Michei, P. and Neey, A. (2006) Performance measurement in the Engish pubic sector: searching for the goden thread. Paper presented at the American Academy of Management Conference, Atanta, August. Mintzberg, H. (1973) The Nature of Manageria Work. London: Harper Coins. Mintzberg, H. (1994) Rounding out the manageria job, Soan Management Review, 36(1): 11 26. Mohr, L.B. (1982) Expaining Organizationa Behaviour: The Limits and Possibiities of Theory and Research. San Francisco: Jossey-Bass Pubishers. Queen's Printer and Controer of HMSO 2013. 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. 133

APPENDIX 1 NHS Institute for Innovation and Improvement (2008) Medica Leadership Competency Framework. Warwick: NHS Institute for Innovation and Improvement. Øvretveit, J. and Asaksen, A. (1999) The Quaity Journeys of Six Norwegian Hospitas: An Action Evauation. Oso: Norwegian Medica Association. Perrow, C. (1999) Norma Accidents: Living With High-Risk Technoogies. New Jersey: Princeton University Press. Pettigrew, A.M. (1990) Longitudina fied research on change: theory and practice, Organization Science, 1(3): 267 92. Pettigrew, A.M., Ferie, E. and McKee, L. (1992) Shaping Strategic Change: Making Change in Large Organizations The Case of the Nationa Heath Service. London: Sage Pubications. Rogers, M.L., Cook, R.I., Bower, R., Mooy, M. and Render, M.L. (2004) Barriers to impementing wrong site surgery guideines: a cognitive work anaysis, IEEE Transactions on Systems, Man & Cybernetics: Part A, 34(6): 757 63. Rousseau, D.M., Manning, J. and Denyer, D. (2008) Evidence in management and organizationa science: assembing the fied's fu weight of scientific knowedge through syntheses, The Academy of Management Annas, 2(1): 475 515. Rueschemeyer, D. (2003) Can one or a few cases yied theoretica gains? in James Mahoney and Dietrich Rueschemeyer (eds), Comparative Historica Anaysis in the Socia Sciences. Cambridge: Cambridge University Press, pp. 305 36. Sambrook, S. (2005) Management deveopment in the NHS: nurses and managers, discourses and identities, Journa of European Industria Training, 30(1): 48 64. Shepherd, A. (2008) Finance: make your business boom, Heath Services Journa, 18 August: www.hsj.co.uk/printpage.htm?pageid=1767141 Shorte, S.M., Runda, T.G. and Hsu, J. (2007) Improving patient care by inking evidence-based medicine and evidence-based management, Journa of the American Medica Association, 298(6): 673 76. Stein, M. (2004) The critica period of disasters: insights from sense-making and psychoanaytic theory, Human Reations, 57(10): 1243 61. Stewart, R. (1997) The Reaity of Management. London: Pan/Heinemann (third edn). The Information Centre (2007) Staff in the NHS 1997 2007. London: The Information Centre. Tsoukas, H. (2009) Craving for generaity and sma-n studies: a Wittgensteinian approach towards the epistemoogy of the particuar in organization and management studies, in David A. Buchanan and Aan Bryman (eds), The Sage Handbook of Organizationa Research Methods. London: Sage Pubications (forthcoming). Turner, B. and Pidgeon, N. (1997) Man-Made Disasters. London: Butterworth Heinemann. (second edn.) Van de Ven, A.H. and Pooe, M.S. (2002) Fied research methods, in Joe A.C. Baum (ed.), The Backwe Companion to Organizations. Maden, MA and Oxford: Backwe Pubishing. pp. 867 88. Vaughan, D. (1999) The dark side of organizations: mistake, misconduct, and disaster, Annua Review of Socioogy, 25(1): 271 305. Waker, H.J., Armenakis, A.A. and Bernerth, J.B. (2007) Factors infuencing organizationa change efforts, Journa of Organizationa Change Management, 20(6): 761 73. Watson, T.J. (1994) In Search of Management: Cuture, Chaos and Contro in Manageria Work. London: Routedge. 134 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Watson, T.J. (1997) Theorizing manageria work: a pragmatic puraist approach to interdiscipinary research, British Journa of Management, 8(1): 3 8. Weick, K.E. (1993) The coapse of sensemaking in organizations: the Mann Guch disaster, Administrative Science Quartery, 38(4): 628 52. Weick, K.E. and Roberts, K.H. (2003) Coective mind in organizations: heedfu interreating on fight decks, Administrative Science Quartery, 38(3): 357 81. West, M.A., Borri, C., Dawson, J., Scuy, J., Carter, M., Aneay, S., Patterson, M. and Waring, J. (2002) The ink between the management of empoyees and patient mortaity in acute hospitas, Internationa Journa of Human Resource Management, 13: 1299 310. Wiiams, M. (2000) Interpretivism and generaization, Socioogy, 34(2): 209 24. Queen's Printer and Controer of HMSO 2013. 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. 135

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Appendix 2 Project documentation Information sheets, topic guides and consent forms are version 1 (9 February 2009) with the exception of the research interview consent form, which is version 2 (4 Apri 2009). Queen's Printer and Controer of HMSO 2013. 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. 137

APPENDIX 2 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the work of midde and front ine heathcare management Setup meetings agenda ogistics 1. Who shoud we ask to hep us to identify the midde and front ine management popuation of the Trust so that we can distribute information about this project? And the key categories and/or groups to whom we shoud be speaking? (Job tites vary, and this project extends to those who describe themseves as cinica and manageria eads.) And who shoud we ask about room avaiabiity and booking? We woud ike to use sma meeting rooms for focus groups with up to 10 participants. background 2. What woud you say are the main issues on the management agenda right now? 3. In your opinion, what are the main pressures and demands ( -s), and motives and rewards ( +s), for the midde and front ine management roes in this trust? 4. eadership - the issues, the chaenges, the benefits? 5. Can you give me a coupe of exampes that iustrate the roe that midde and front ine managers have payed in this Trust to improve cinica outcomes and quaity of care? 6. - what in your view are three things the Trust does we, three things the Trust does not do so we? 7. What do you think has to change in this Trust to aow midde and front ine managers to make an even stronger contribution to patient care and organizationa performance? outputs 8. What outcomes and benefits woud you ike to get from this project - from a persona perspective, a Trust perspective, from the perspective of the service as a whoe? 9. What other issues woud you advise us to be aware of and to ook out for in this study of midde and front ine management work? 138 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare How do you manage? Can you hep us to understand how management work is changing and why? This wi ead to new management deveopment approaches, and aso to new practices, toos, diagnostics and frameworks which wi hep you to impement change, improve patient safety, and infuence care quaity, cinica outcomes, and organizationa performance. Focus Group Participant Information Sheet How are midde and front ine management roes in heathcare changing? What are the chaenges and rewards, the pressures and the satisfactions? And what are the impications? We woud ike to ask you to hep us to answer these questions. This wi improve our understanding of management roes, and of management support and deveopment needs, and wi contribute to improvements in management practice. The focus groups wi be hed on Trust premises, invove around eight managers on each occasion, and wi ast about an hour. 1. What is the purpose of this study? The aim of this project is to improve our understanding of how heathcare managers hande the demands and chaenges, the motivations and rewards, of a changing service. We know very itte about the work experience and attitudes of heathcare managers, but when things go wrong, this group often takes the bame. We wi expore the impact managers have on the quaity and outcomes of patient care, and we aso want to find out how changes to working practices are managed after serious incidents. This can be a probem, as the recommendations of enquiries, in heath and esewhere, often sit on the shef. 2. Who ese is invoved in this study? Organizations coaborating in this work incude six acute trusts and one primary care trust. Members of the research team wi meet with senior managers at each ocation before data coection begins, to answer questions, and to make appropriate ogistica arrangements. We have an advisory group incuding senior heathcare managers in nationa, regiona, and oca roes, to ensure that our work is up to date with current trends and deveopments, and to hep with carifying the practica impications and dissemination of findings. At each participating trust, our focus ies with midde and front ine managers, and some senior (board eve) managers may aso be invoved. There is no patient invovement in this study. Queen's Printer and Controer of HMSO 2013. 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. 139

APPENDIX 2 3. What wi be invoved if I decide to take part? We expect a ivey focus group discussion of the main motivations and rewards of midde and front ine management work in heathcare, how management roes are evoving with current pressures, and what woud have to change in order to strengthen the contribution that you make to quaity of patient care, cinica outcomes, and overa organizationa effectiveness. 4. Wi the information obtained in the study be confidentia? We guarantee that your participation in this study, and a information that you provide, wi be treated confidentiay. We wi abide by a reevant sections of the Data Protection Act 1998, and guarantee conformity with its principes. Interview transcripts wi be coded anonymousy and stored on secure digita media. A origina data (computer fies, hard copy) wi be destroyed five years after the end of the study. Information gathered wi be used ony for the purposes of this study and the dissemination of resuts. Information from different sources wi be aggregated for the presentation of findings in reports and academic pubications: individuas, departments and Trusts wi not be identifiabe. If, for iustrative purposes, verbatim quotations from focus and briefing groups and interviews are used, individua and organizationa identity cues wi be removed, and quotes wi not be attributed. If you woud ike a copy of the fina report of this study, this wi be provided free of charge on request. The research team members are covered by professiona indemnity insurance which provides remedies for breach of confidentiaity. 5. If I have concerns about this study, or if I change my mind about taking part? If you have any concerns either during or after the study, pease contact the Principa Investigator. Your decision to take part in this study, or not, wi be confidentia. If you choose to be invoved and then withdraw, your decision wi be respected without question, and wi be treated as confidentia. 6. What if I woud ike further information about this study? If you woud ike to discuss this study in more detai, pease contact either the Principa Investigator, or the designated member of the research team at your Trust who wi be happy to answer questions. They can be reached through the Cranfied switchboard: 01234 751122. Professor David Buchanan (Principa Investigator) Dr Catherine Baiey Dr Care Keiher Dr Janice Osbourne Dr Coin Pibeam Professor Kim Turnbu James Dr David Denyer Moore Dr Emma Parry Dr Janet Price Dr Chares Wainwright 140 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 7. What if I have any other concerns? If you have any other concerns or questions about this study, at any stage, pease contact the Principa Investigator, or a member of the management board of your trust. Emai: David.Buchanan@Cranfied.ac.uk This project is funded by the NHS Nationa Institute for Heath Research Service Deivery and Organization Research & Deveopment Programme Queen's Printer and Controer of HMSO 2013. 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. 141

APPENDIX 2 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare How do you manage? Can you hep us to understand how management work is changing and why? This wi ead to new management deveopment approaches, and aso to new practices, toos, diagnostics and frameworks which wi hep you to impement change, improve patient safety, and infuence care quaity, cinica outcomes, and organizationa performance. Survey Respondent Information Sheet How are midde and front ine management roes in heathcare changing? What are the chaenges and rewards, the pressures and the satisfactions? And what are the impications? We woud ike to ask you to hep us to answer these questions. This wi improve our understanding of management roes, and of management support and deveopment needs, and wi contribute to improvements in management practice. The survey questionnaire has been designed to be easy to compete, and shoud take you no more than haf an hour. 1. What is the purpose of this study? The aim of this project is to improve our understanding of how heathcare managers hande the demands and chaenges, the motivations and rewards, of a changing service. We know very itte about the work experience and attitudes of heathcare managers, but when things go wrong, this group often takes the bame. We wi expore the impact managers have on the quaity and outcomes of patient care, and we aso want to find out how changes to working practices are managed after serious incidents. This can be a probem, as the recommendations of enquiries, in heath and esewhere, often sit on the shef. 2. Who ese is invoved in this study? Organizations coaborating in this work incude six acute trusts and one primary care trust. Members of the research team wi meet with senior managers at each ocation before data coection begins, to answer questions, and to make appropriate ogistica arrangements. We have an advisory group incuding senior heathcare managers in nationa, regiona, and oca roes, to ensure that our work is up to date with current trends and deveopments, and to hep with carifying the practica impications and dissemination of findings. At each participating trust, our focus ies with midde and front ine managers, and some senior (board eve) managers may aso be invoved. There is no patient invovement in this study. 142 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 3. What wi be invoved if I decide to take part? We wi ask you to compete a survey questionnaire, which wi take about haf an hour to compete. Questions wi be about the reaities of the heathcare management roe, the impementation of changes to working practices, and how managers contribute to quaity of patient care, cinica outcomes, and organizationa effectiveness. You wi not be asked to put your name on the questionnaire, which we wi ask you to pace in an unmarked enveope, which wi then be returned directy to, or personay coected by a member of the research team, so that your responses remain anonymous. 4. Wi the information obtained in the study be confidentia? We guarantee that your participation in this study, and any information that you provide, wi be treated confidentiay. We wi abide by a reevant sections of the Data Protection Act 1998, and guarantee conformity with its principes. Survey responses are anonymous, and interview transcripts wi be coded anonymousy and stored on secure digita media. A origina data (computer fies, hard copy) wi be destroyed five years after the end of the study. Information gathered wi be used ony for the purposes of this study and the dissemination of resuts. Information from different sources wi be aggregated for the presentation of findings in reports and academic pubications: individuas, departments and Trusts wi not be identifiabe. If, for iustrative purposes, verbatim quotations from focus groups and interviews are used, individua and organizationa identity cues wi be removed, and quotes wi not be attributed. If you woud ike a copy of the fina report of this study, this wi be provided free of charge on request. The research team members are covered by professiona indemnity insurance which provides remedies for breach of confidentiaity. 5. If I have concerns about this study, or if I change my mind about taking part? If you have any concerns either during or after the study, pease contact the Principa Investigator. Your decision to take part in this study, or not, wi be confidentia. If you choose to be invoved and then withdraw, your decision wi be respected without question, and wi be treated as confidentia. 6. What if I woud ike further information about this study? If you woud ike to discuss this study in more detai, pease contact either the Principa Investigator, or the designated member of the research team at your Trust who wi be happy to answer questions. They can be reached through the Cranfied switchboard: 01234 751122. Professor David Buchanan (Principa Investigator) Dr Catherine Baiey Dr Care Keiher Dr Janice Osbourne Dr Coin Pibeam Professor Kim Turnbu James Dr David Denyer Dr Emma Parry Dr Janet Price Dr Chares Wainwright Queen's Printer and Controer of HMSO 2013. 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. 143

APPENDIX 2 7. What if I have any other concerns? If you have any other concerns or questions about this study, at any stage, pease contact the Principa Investigator, or a member of the management board of your trust. Emai: David.Buchanan@Cranfied.ac.uk This project is funded by the NHS Nationa Institute for Heath Research Service Deivery and Organization Research & Deveopment Programme 144 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare How do you manage? Can you hep us to understand how management work is changing and why? This wi ead to new management deveopment approaches, and aso to new practices, toos, diagnostics and frameworks which wi hep you to impement change, improve patient safety, and infuence care quaity, cinica outcomes, and organizationa performance. Briefing Group Participant Information Sheet We woud ike to te you about the findings of this research project so far - from focus groups and a management survey - and to ask you for your assessment of our resuts, and what you fee are the impications for management practice. We woud aso ike to ask you to hep us to generate nove practica ideas with regard to the wider dissemination of these findings to the management community across the service. The next stage of this project wi invove a sma number of cases examining how change is managed foowing serious incidents. We woud ike your hep to identify appropriate cases to expore. 1. What is the purpose of this study? The aim of this project is to improve our understanding of how heathcare managers hande the demands and chaenges, the motivations and rewards, of a changing service. We know very itte about the work experience and attitudes of heathcare managers, but when things go wrong, this group often takes the bame. We wi expore the impact managers have on the quaity and outcomes of patient care, and we aso want to find out how changes to working practices are managed after serious incidents. This can be a probem, as the recommendations of enquiries, in heath and esewhere, often sit on the shef. 2. Who ese is invoved in this study? Organizations coaborating in this work incude six acute trusts and one primary care trust. Members of the research team met with senior managers at each ocation before data coection began, to answer questions, and to make appropriate ogistica arrangements. We have an advisory group incuding senior heathcare managers in nationa, regiona, and oca roes, to ensure that our work is up to date with current trends and deveopments, and to hep with carifying the practica impications and dissemination of findings. At each participating trust, our focus ies with midde and front ine managers, and some senior (board eve) managers may aso be invoved. There is no patient invovement in this study. Queen's Printer and Controer of HMSO 2013. 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. 145

APPENDIX 2 3. What wi be invoved if I decide to take part? At this briefing, we wi present an overview of what we beieve to be the findings of this study so far. We wi ask for your assessment of our anaysis, eading to a discussion of the impications for management k you to hep choose case incidents for the next stage of the project, those events. 4. Wi the information obtained in the study be confidentia? We guarantee that your participation in this study, and a information that you provide, wi be treated confidentiay. We wi abide by a reevant sections of the Data Protection Act 1998, and guarantee conformity with its principes. Interview transcripts wi be coded anonymousy and stored on secure digita media. A origina data (computer fies, hard copy) wi be destroyed five years after the end of the study. Information gathered wi be used ony for the purposes of this study and the dissemination of resuts. Information from different sources wi be aggregated for the presentation of findings in reports and academic pubications: individuas, departments and Trusts wi not be identifiabe. If, for iustrative purposes, verbatim quotations from focus and briefing groups and interviews are used, individua and organizationa identity cues wi be removed, and quotes wi not be attributed. If you woud ike a copy of the fina report of this study, this wi be provided free of charge on request. The research team members are covered by professiona indemnity insurance which provides remedies for breach of confidentiaity. 5. If I have concerns about this study, or if I change my mind about taking part? If you have any concerns either during or after the study, pease contact the Principa Investigator. Your decision to take part in this study, or not, wi be confidentia. If you choose to be invoved and then withdraw, your decision wi be respected without question, and wi be treated as confidentia. 6. What if I woud ike further information about this study? If you woud ike to discuss this study in more detai, pease contact either the Principa Investigator, or the designated member of the research team at your Trust who wi be happy to answer questions. They can be reached through the Cranfied switchboard: 01234 751122. Professor David Buchanan (Principa Investigator) Dr Catherine Baiey Dr Care Keiher Dr Janice Osbourne Dr Coin Pibeam Professor Kim Turnbu James Dr David Denyer Dr Emma Parry Dr Janet Price Dr Chares Wainwright 146 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 7. What if I have any other concerns? If you have any other concerns or questions about this study, at any stage, pease contact the Principa Investigator, or a member of the management board of your trust. Emai: David.Buchanan@Cranfied.ac.uk This project is funded by the NHS Nationa Institute for Heath Research Service Deivery and Organization Research & Deveopment Programme Queen's Printer and Controer of HMSO 2013. 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. 147

APPENDIX 2 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare How do you manage? Can you hep us to understand how management work is changing and why? This wi ead to new management deveopment approaches, and aso to new practices, toos, diagnostics and frameworks which wi hep you to impement change, improve patient safety, and infuence care quaity, cinica outcomes, and organizationa performance. Case Study Interviewee Information Sheet We woud ike to expore your experience of the conditions in which change after a serious event can be either straightforward, or chaenging. This wi improve our understanding of the processes invoved in such circumstances, and deveop guideines for improved practice which wi in turn contribute to patient safety. The interview wi be hed on Trust premises, at a time convenient for you, and wi ast about an hour. 1. What is the purpose of this study? The aim of this project is to improve our understanding of how heathcare managers hande the demands and chaenges, the motivations and rewards, of a changing service. We know very itte about the work experience and attitudes of heathcare managers, but when things go wrong, this group often takes the bame. We wi expore the impact managers have on the quaity and outcomes of patient care, and we aso want to find out how changes to working practices are managed after serious incidents. This can be a probem, as the recommendations of enquiries, in heath and esewhere, often sit on the shef. 2. Who ese is invoved in this study? Organizations coaborating in this work incude six acute trusts and one primary care trust. Members of the research team met with senior managers at each ocation before data coection began, to answer questions, and to make appropriate ogistica arrangements. We have an advisory group incuding senior heathcare managers in nationa, regiona, and oca roes, to ensure that our work is up to date with current trends and deveopments, and to hep with carifying the practica impications and dissemination of findings. At each participating trust, our focus ies with midde and front ine managers, and some senior (board eve) managers may aso be invoved. There is no patient invovement in this study. 3. What wi be invoved if I decide to take part? This interview wi take about an hour, focusing on an incident with which you have experience, and in particuar on the impications for organizationa change. Athough it wi be based on a topic guide, we wi rey on your judgement and preferences with regard to the information that you discose, and the sequence in which topics are covered. We wish to record interviews so that we can produce accurate accounts, and we wi give you a copy of the transcript on request. However, we wi ask your permission before recording, 148 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 and we wi respect without question your right to withhod that permission. Depending on how this case study deveops, we may ask if we can interview you again, under the same conditions. Your consent to that request wi of course be vountary, and we wi respect without question your decision regarding whether or not to contribute further. In exporing how change was managed foowing a serious incident, it is possibe that you may find yoursef sharing information about work experiences that you found difficut or distressing. If you are unwiing to share such information, pease consider this when making your decision to be interviewed. If you fee uncomfortabe during the interview, simpy inform the research team member who wi then terminate the discussion, and who wi offer to discuss the experience in private, off the record, if you woud find that hepfu. 4. Wi the information obtained in the study be confidentia? We guarantee that your participation in this study, and a information that you provide, wi be treated confidentiay. We wi abide by a reevant sections of the Data Protection Act 1998, and guarantee conformity with its principes. Interview transcripts wi be coded anonymousy and stored on secure digita media. A origina data (computer fies, hard copy) wi be destroyed five years after the end of the study. Information gathered wi be used ony for the purposes of this study and the dissemination of resuts. Information from different sources wi be aggregated for the presentation of findings in reports and academic pubications: individuas, departments and Trusts wi not be identifiabe. If, for iustrative purposes, verbatim quotations from focus and briefing groups and interviews are used, individua and organizationa identity cues wi be removed, and quotes wi not be attributed. If you woud ike a copy of the fina report of this study, this wi be provided free of charge on request. The research team members are covered by professiona indemnity insurance which provides remedies for breach of confidentiaity. 5. If I have concerns about this study, or if I change my mind about taking part? If you have any concerns either during or after the study, pease contact the Principa Investigator. Your decision to take part in this study, or not, wi be confidentia. If you choose to be invoved and then withdraw, your decision wi be respected without question, and wi be treated as confidentia. 6. What if I woud ike further information about this study? If you woud ike to discuss this study in more detai, pease contact either the Principa Investigator, or the designated member of the research team at your Trust who wi be happy to answer questions. They can be reached through the Cranfied switchboard: 01234 751122. Professor David Buchanan (Principa Investigator) Dr Catherine Baiey Dr Care Keiher Dr Janice Osbourne Dr Coin Pibeam Professor Kim Turnbu James Dr David Denyer Dr Emma Parry Dr Janet Price Dr Chares Wainwright Queen's Printer and Controer of HMSO 2013. 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. 149

APPENDIX 2 7. What if I have any other concerns? If you have any other concerns or questions about this study, at any stage, pease contact the Principa Investigator, or a member of the management board of your trust. Emai: David.Buchanan@Cranfied.ac.uk This project is funded by the NHS Nationa Institute for Heath Research Service Deivery and Organization Research & Deveopment Programme 150 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare Management focus group topic guide How are midde and front ine management roes in heathcare changing? And what are the impications? We woud ike to ask you to hep us to answer these questions. This information wi be vauabe in its own right, and wi hep us with the design of the survey in the next stage of this project. That survey wi have common items that we wi use in other trusts taking part in this study. But we aso want to taior the questions to oca needs and priorities. Can we address any questions or concerns that you have before we start? Individua brief: 5 minutes From your experience: 1. what are the main motivations and rewards in your current roe? 2. how is your management roe in this Trust changing? 3. what woud have to change in order to strengthen the contribution that you as a manager can make to improve the quaity of patient care and cinica outcomes? 4. what woud have to change in order to strengthen the contribution that you as a manager can make to improve overa organizationa effectiveness? Tabe brief: 25 minutes In groups of three to five, share your answers to those questions, and coate the resuts on the fipcharts provided. Nominate a spokesperson (or two) to feed back to the whoe group. Penary: 20 minutes Feedback from spokespersons and open discussion. Cose: 5 minutes Fina questions, issues, how this information wi be used. This project is funded by the NHS Nationa Institute for Heath Research Service Deivery and Organization Research & Deveopment Programme Queen's Printer and Controer of HMSO 2013. 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. 151

APPENDIX 2 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare Management briefing group topic guide In this briefing group, we woud ike to expain the main findings of this project so far, from focus groups and our management survey. In making this presentation, we woud ike to ask for your comments, advice and suggestions in the foowing areas: 1. Are these findings what you woud have expected, or not, and why? 2. Is our interpretation of these resuts consistent with your own experience? 3. What in your view are the practica management impications of these findings? 4. We woud ike to deveop innovative ways to disseminate these findings, so that they have a rapid and significant impact on management practice; what woud you recommend? 5. For the next stage of this project, we want to expore the management of changes foowing serious or adverse incidents. This wi incude instances where changes were successfu, as we as situations where change was probematic. These exampes do not have to be current or recent. The main criterion in choosing cases to study is the opportunity to earn about the change processes that foow such events. We woud ike to ask you to hep us to identify potentiay suitabe cases. This project is funded by the NHS Nationa Institute for Heath Research Service Deivery and Organization Research & Deveopment Programme 152 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Canfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare Case incident interview topic guide We woud ike to cover these topics, if they are reevant to you and to the incident that we are studying. We wi rey on your judgement and preferences with regard to the information that you wish to discose. We there any questions or concerns before we begin? the trigger incident consequences, damage, oss stakehoders, groups, agencies other organizations invoved enquiry, who, when, how causes, expanations how did this affect you? how did it affect others? attribution of cause has something ike this happened before, and when? your roe in these events? what happened ast time? earning, recommendations for change your view of this outcome? what has changed, and why? what has not changed, and why? barriers to change? This project is funded by the NHS Nationa Institute for Heath Research Service Deivery and Organization Research & Deveopment Programme Queen's Printer and Controer of HMSO 2013. 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. 153

APPENDIX 2 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare Research Focus Group Consent Form I agree to take part in this study as described in the Participant Information Sheet (version 1 dated 09.02.09) which I have read. I have had the opportunity to discuss detais with a member of the research team, and to ask questions. The nature and purpose of this study have been expained to me, and I understand what wi be required if I decide to take part. I understand that my participation is vountary and confidentia, and that I may withdraw at any time, before or during the focus group meeting, without justifying my decision. I consent to the arrangements for data storage and the use to which the information that I provide may be put. I understand that the information that I discose wi be treated in confidence, and that my comments if cited wi be presented in an anonymous manner that does not identify the source. I understand that the transcript of this focus group meeting wi ony be seen by members of the research team. Signature of participant Name in BLOCK LETTERS Date / /_2011 I confirm that I have expained the nature of the study as detaied in the Participant Information Sheet, in terms which in my judgement are suited to the understanding of the participant. Signature of research team member Name in BLOCK LETTERS Date / /_20011 This project is funded by the NHS Nationa Institute for Heath Research Service Deivery and Organization Research & Deveopment Programme 154 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare Research Briefing Group Consent Form I agree to take part in this study as described in the Participant Information Sheet (version 1 dated 09.02.09) which I have read. I have had the opportunity to discuss detais with a member of the research team, and to ask questions. The nature and purpose of this study have been expained to me, and I understand what wi be required if I decide to take part. I understand that my participation is vountary and confidentia, and that I may withdraw at any time, before or during the briefing group meeting, without justifying my decision. I consent to the arrangements for data storage and the use to which the information that I provide may be put. I understand that the information that I discose wi be treated in confidence, and that my comments if cited wi be presented in an anonymous manner that does not identify the source. I understand that the transcript of this briefing group meeting wi ony be seen by members of the research team. Signature of participant Name in BLOCK LETTERS Date / /_2011 I confirm that I have expained the nature of the study as detaied in the Participant Information Sheet, in terms which in my judgement are suited to the understanding of the participant. Signature of research team member Name in BLOCK LETTERS Date / /_2011 This project is funded by the NHS Nationa Institute for Heath Research Service Deivery and Organization Research & Deveopment Programme Queen's Printer and Controer of HMSO 2013. 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. 155

APPENDIX 2 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare Research Interview Consent Form I agree to take part in this study as described in the Participant Information Sheet, which I have read. I have had the opportunity to discuss detais with a member of the research team, and to ask questions. The nature and purpose of this study have been expained to me, and I understand what wi be required if I decide to take part. I understand that my participation is vountary and confidentia, and that I may withdraw at any time, before or during the interview, without justifying my decision. I consent to the arrangements for data storage and the use to which the information that I provide may be put. I understand that the information that I discose wi be treated in confidence, and that my comments if cited wi be presented in an anonymous manner that does not identify the source. Pease initia one of the foowing options I consent to an audio recording being made of this interview I understand that the transcript wi ony be seen by mysef, and by members of the research team, and that the recording wi be deeted once the transcript has been made. I do not consent to an audio recording being made of this interview Signature of participant Name in BLOCK LETTERS Date / /_2011 I confirm that I have expained the nature of the study as detaied in the Participant Information Sheet, in terms which in my judgement are suited to the understanding of the participant. Signature of research team member Name in BLOCK LETTERS Date / /_2011 This project is funded by the NHS Nationa Institute for Heath Research Service Deivery and Organization Research & Deveopment Programme 156 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Cranfied University Schoo of Management and Cranfied Heath How do they manage? a study of the reaities of midde and front ine management work in heathcare Advisory Group David Grantham Katheen Hunter Director of Human Resources and Organization & Deveopment Research and Deveopment Manager Kingston Hospita NHS Trust Miton Keynes Hospita Vaerie Ies Director Reay Learning Simone Jordan Susan Lawrence Director of Workforce and Human Resources Operations Manager, Surgica Services Operations Manager, Medicine, and SDO Management Feow NHS East Midands Strategic Heath Authority Cambridge University Hospitas Cambridge University Hospitas Nei Offey Director Nei Offey Consuting Ltd Graeme Currie Professor of Pubic Management Warwick Business Schoo Jacky Hooway Head, Centre for Pubic Leadership and Socia Enterprise Open University Business Schoo The advisory group wi meet reguary over the ife of the project, 2009 to 2011. Meetings wi coincide with events and outputs, ensuring a substantive agenda on each occasion. The principe aims of the advisory group are: to provide the project team with a critica and creative sounding board, with regard to ideas and findings, and aso with regard to project progress against aims and deadines to highight trends, deveopments, issues, and themes that deserve our coser attention to hep us to identify the practica manageria impications of the study to direct us to stakehoder groups with whom we shoud be engaging to hep us to identify innovative forms and channes of communication for the findings potentiay contribute to the deveopment of joint pubications arising from this study.... and any other issues that arise.... Queen's Printer and Controer of HMSO 2013. 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. 157

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Appendix 3 Management survey Queen's Printer and Controer of HMSO 2013. 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. 159

APPENDIX 3 How do they manage? a study of the reaities of midde and front ine management work in heathcare Management Survey 2011 Whoe sampe This report shows the combined frequency distributions (percentages) for the 611 responses to this survey from five participating acute trusts. The survey was administered by emai during the ast four months of caendar 2011. Separate reports show the pattern of responses at each of the five acute trusts respectivey. Emma Parry and David Buchanan: 8 March 2012 160 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Headines highy motivated, deepy committed where is the negative stereotype of heathcare management? change- and improvementorientated 75% are motivated by making a difference to patient webeing 90% are motivated by deveoping others 94% ike to fee their work contributes to the organization 60% said cinica staff vaued their management contribution 70% did not resent reducing cinica duties to do management work 76% were happy to be seen as a manager 42% said they were empowered to act to fix probems 65% said they exercised infuence in their areas 78% agreed that they had become more businessike stretched by heavy workoads and under-resourcing - intense, ong hours, fast pace 30% said resources were sufficient for their roe 58% said their roe was unmanageabe 68% said they did not have enough time for their management duties 80% said that pressure to meet targets has risen 90% agreed that focus on cost effectiveness has increased 68% said their manageria responsibiities were expanding 77% said they constanty had to respond instanty 80% said they were aways chasing deadines 83% often arrive eary and eave ate 93% said they had to improve services with reduced resources patient safety is compromised in the current financia cimate satisfaction with organization ow, job satisfaction higher cear about own roes, uncear about who is in charge the persona costs of a management roe disaffection is significant 51% said tradeoffs were made between safety, quaity, and finance 54% agreed that financia pressures put patient safety at risk 70% s 28% were satisfied with their organization 50% were satisfied with their job 56% sa 70% agreed that they were cear about their roe 30% said they coud maintain satisfactory work-ife baance 50% worry about probems, have difficuty unwinding, and fee used up and exhausted after work 26% said an offer of more money woud make them think of eaving 42% said they sometimes fet ike eaving for good 44% said they had reevant capabiities not being used in their roe Queen's Printer and Controer of HMSO 2013. 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. 161

APPENDIX 3 Reaities of the job item strongy disagree neither agree or disagree strongy agree The need for me to focus on cost effectiveness has increased 4.0 2.5 5.8 24.4 63.2 4.0 19.2 20.7 36.4 19.7 The amount of bureaucracy that I need to dea with has increased The need for me to be more businessike (i.e. manage my department more ike a commercia organization) has increased The need for managers to use evidence- based interventions in their practice has increased The pressure for my department to meet targets has increased The expectation that cinica staff wi take on manageria roes has increased Athough my roe incudes management responsibiities, I do not ike to be seen as a manager I am cear about the requirements of my manageria roe 2.3 4.3 15.9 33.8 43.7 2.0 5.3 14.9 35.5 42.3 3.3 6.9 24.6 39.8 25.4 3.5 3.3 10.1 26.7 56.4 2.6 3.6 22.6 31.8 39.5 22.2 27.2 26.7 11.9 11.9 4.2 13.6 9.4 30.8 42 My overa workoad is usuay manageabe 22.3 35.3 11.4 22.8 8.1 I have enough time to compete a of my management duties I am abe to maintain a satisfactory work-ife baance I am abe to exert infuence in my area of the organization Other empoyees have negative attitudes towards this organization I am abe to exert infuence in other parts of the organization My management contribution is vaued by cinica staff 29.5 38.9 10.4 16.0 5.1 19.5 27.2 19.0 23.4 10.9 6.8 14.6 13.8 37.5 27.3 2.1 14.3 23.2 33.3 27.1 12.7 18.9 22.2 34.1 12.1 3.7 11.2 25.5 40.2 19.4 162 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agree I have the necessary authority to make management decisions at my eve I have received sufficient training for my management roe I was given a choice as to whether or not I took on a management roe I have a probem accepting management responsibiities Most cinica staff do not have the peope skis required to drive change I sometimes fee uncomfortabe managing my professiona peers I have sufficient resources to carry out my management responsibiities effectivey I often strugge to baance the priorities of both my manageria and cinica roes I have had to reduce my cinica work to fufi my management duties I fee resentfu of having to reduce my cinica responsibiities in order to undertake manageria work 7.5 14.7 14.7 36.6 26.5 7.3 19.8 21.9 29.4 21.6 9.2 15.6 19.0 23.1 33.1 54.5 26.5 11.2 4.2 3.6 16.8 27.5 29.9 16.0 9.6 24.3 28.9 17.7 22.6 6.5 16.2 35.8 18.0 22.2 7.7 6.5 16.5 23.7 24.8 28.4 9.8 20.7 25.4 22.8 21.4 10.0 22.3 38.1 18.1 11.5 objectives and pans It is easy for me to form good working reationships with coeagues In this organization I see eadership operating at a eves There are not many good manageria roe modes in this organization I receive support for my manageria roe from my persona networks 5.8 7.4 16.8 38.9 31.1 2.7 2.7 4.1 43.8 46.7 9.4 24.7 22.7 28.1 15.1 7.5 24.9 28.8 21.6 17.2 5.7 12.3 26.9 34.7 20.4 It is aways cear who is in charge of a situation 10.0 38.2 23.8 20.5 7.4 Queen's Printer and Controer of HMSO 2013. 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. 163

APPENDIX 3 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agree In my experience, managers fee empowered to take charge when they have something to offer I have reevant capabiities that I am not abe to use in my current position As the pressure on me increases, I have to pass the pressure on to the staff for whom I am responsibe It is becoming harder to motivate staff in the current cost-cutting cimate I have had to accept responsibiity for tasks that are beyond my ski and experience 5.6 20.8 31.3 34.4 7.9 6.3 21.1 28.2 22.6 21.8 8.2 21.3 19.5 37.6 13.4 2.7 14.6 11.7 37.9 33.2 14.9 32.5 24.0 19.6 9.0 We do not have good peer group support here 11.6 29.5 22.7 21.4 14.7 164 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Job characteristics item strongy disagree neither agree or disagree strongy agree job 3.7 17.2 24.9 30 24.1 meet another deadine 0.5 6.9 11.2 41.6 39.7 My management responsibiities just seem to keep expanding 0.0 11.2 21.1 34.4 33.3 I am constanty expected to respond instanty 0.5 7.8 15.1 35.2 41.4 I am responsibe for showing ess experienced staff how to perform effectivey I frequenty arrive earier and/or eave ater than my contract requires I make decisions that directy affect the ives of patients 0.5 7.1 14.1 43.2 35.1 2.8 5.3 9.1 21.3 61.5 6.3 6.7 10.7 26.7 49.7 My priorities change every week 3.8 15.5 23.1 31.9 25.7 I am expected to improve the service we provide despite resources being cut A ot of my time is spent responding to requests for information, reports and action pans I have to get arge numbers of peope to agree even to make sma changes 1.4 1.4 4.7 27.4 65.1 2.7 7.1 14.2 34.8 41.1 2.8 11.8 19.0 35.0 31.4 15.0 28.2 25.2 19.8 11.8 in my job In my job I get to work with high-caibre coeagues 3.2 11.2 15.0 38.0 32.6 2.4 10.2 19.4 36.7 31.3 I am we paid for what I do 12.6 13.7 26.0 33.2 14.5 I get recognition for my achievements in this job 14.2 23.3 22.7 27.3 12.6 I enjoy the power and status that I have in my roe 8.8 13.3 41.5 28.2 8.2 Queen's Printer and Controer of HMSO 2013. 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. 165

APPENDIX 3 Persona and organizationa outcomes item strongy disagree neither agree or disagree strongy agree I am motivated by deveoping other empoyees 0.8 2.7 6.8 42.3 47.4 My management roe aows me to make a difference to patient we being I am proud to be abe to te peope who it is I work for I sometimes fee ike eaving this empoyment for good 1.5 5.8 18.1 41.4 33.2 2.4 9.7 22.6 34.8 30.5 19.7 19.5 19.2 26.2 15.4 I woud not recommend a friend to join our staff 27.2 28.3 25.9 11.3 7.3 organization ef out just to hep the 53.0 32.5 8.6 3.8 2.2 In spite of financia pressures, I woud be reuctant to change to another empoyer 8.1 10.5 29.6 25.5 26.3 I fee mysef to be part of the organization 4.3 8.6 19.6 39.4 28.2 In my work I ike to fee I am making some effort, not just for mysef, but for the organization as we The offer of a bit more money with another empoyer woud not seriousy make me think of changing my job To know my own work had made a contribution to the good of the organization woud pease me Patient safety is never put at risk because of financia pressures It is sometimes inevitabe that patient safety is put at risk I have taken decisions that benefit patients, knowing that I have gone over budget as a resut It is often necessary to make a trade off between patient safety, quaity of care and financia targets 0.8 1.9 9.3 39.8 48.1 9.4 16.4 24.4 26.0 23.9 0.6 1.1 3.9 36.9 57.5 22.1 31.8 23.5 15.1 7.5 15.7 19.9 26.7 28.7 9.0 3.4 9.0 25.5 36.6 25.5 12.9 14.4 21.4 32.8 18.5 166 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Job satisfaction item very dissatisfied very satisfied Considering everything, how satisfied are you with your job? Considering everything, how woud you rate your overa satisfaction with your organization at the present time? 5.2 12.8 32.3 40.5 9.2 9.8 24.7 37.8 22.8 4.9 very poor very good How woud you rate this organization to work for compared to others? 3.8 13.7 44.5 28.8 9.2 Persona experience item never occasionay some of the time much of the time most of the time a of the time I worry about probems after work 1.6 14.7 34.0 23.0 21.1 5.6 I find it difficut to unwind after work 2.9 26.3 27.9 20.9 16.4 5.6 I fee used up after work 3.8 17.2 25.3 22.8 23.1 7.8 I fee exhausted after work 4.0 17.4 25.7 20.4 23.3 9.1 item never occasionay some of the time much of the time most of the time a of the time I worry about probems after work 1.6 14.7 34.0 23.0 21.1 5.6 I find it difficut to unwind after work 2.9 26.3 27.9 20.9 16.4 5.6 I fee used up after work 3.8 17.2 25.3 22.8 23.1 7.8 I fee exhausted after work 4.0 17.4 25.7 20.4 23.3 9.1 Queen's Printer and Controer of HMSO 2013. 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. 167

APPENDIX 3 Survey distribution Five of the six acute trusts coaborating in this project took part in this management survey. The sixth, Watte Park, was invoved during 2011 in panning a merger with two other hospitas, and conducting a management survey at that time was considered inappropriate. The other five trusts were asked to distribute the survey, by emai, to their midde management popuation, covering those groups which had contributed to the focus group stage of the project. In other words, the aim was to incude a staff who had either a whoy management roe or a hybrid cinica-manageria roe, from ward sister, through genera and operationa managers, department heads, and cinica directors. Foowing NHS research governance and ethics practice, the emais inviting staff to take part in this project at each trust came not from members of the research team, but from the office of a senior member of the trust staff, or from someone whom that senior staff member had nominated - a persona assistant or a coeague. This meant that the timing of the emai distribution was out of the direct contro of the research team. In most cases the emai distribution was deayed, due to trust staff changes, pressure of work, and other issues and considerations. In addition, whie a cover emai was prepared for trust staff to use, expaining the survey aims and guaranteeing anonymity and confidentiaity, this emai was not used in every case, being overooked in the handover from one member of trust staff to another, or considered too engthy and technica. The cover emais contained unique embedded inks to the onine survey, so that responses coud be identified by trust. As the foowing discussion shows, the survey distribution pattern varied across the five trusts. The widest distribution was at Cearview, significanty aided by the presence and efforts of the SDO Management Feow seconded to this project. The survey at Cearview was sent to over 1,300 staff in thirteen emai distribution groups: heads of service, cinica service managers, administrative service managers, senior sisters, cinica directors, practice deveopment nurses, speciaist nurses, senior cinica nurses, directors and associate directors of operations, staffing administrators, operationa and divisiona managers, medica secretaries, and cinica co-ordinators. At Greenhi, in contrast, given the pressures that staff were facing in the second haf of 2011, the hospita management board decided -section of staff who were considered key to e change agenda and who were supported by an interna eadership deveopment programme. At Netherby, the survey was sent to seven distribution ists incuding consutants, department heads, directorate managers, cinica directors, senior cinica nurses, nurses, and pharmacy. At Burnside, the survey was distributed to a staff on saary band 7 (ward sister) and above. Finay, at South Netey, the survey was distributed to around 200 participants on the trust eadership deveopment programme, and to a cross-section of staff on saary band 7 and above (but the seection criteria for this cross-section was not made cear.) repied foowing a second prompt emai) to 19 per cent at Cearview and Netherby. The overa response rate was 24 per cent. 168 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Sampe characteristics trust distribution usabe responses response rate (%) Cearview 1330 250 19 Burnside 260 108 42 Greenhi 107 77 72 Netherby 453 86 19 South Netey 414 90 22 totas 2,564 611 24% Of the tota, 18 per cent had whoy management roes, and 51 per cent had hybrid cinica-manageria roes; 31 per cent did not answer this question. The higher proportion of hybrid responses is consistent with the composition of the management popuation of acute trusts. Of the tota, 42 per cent were femae, and 19 per cent were mae; 39 per cent did not answer this question. The hybrids, on average, indicated that from their job descriptions, they were supposed to spend 57 per cent of their time on cinica work, and 48 per cent on manageria work. Their actua aocations were 55 per cent cinica and 50 per cent manageria (these responses do not tota to 100 per cent). Many respondents did not answer a questions, some of which were not appicabe to everyone. For most items the numbers responding is around 400. A further expanation for missing data concerned suspicion (fed back to us informay from trust management) that the survey was not anonymous, as individuas coud potentiay be identified on the basis of persona information. However, respondents were not asked to revea job tites, and the survey briefing emphasized data protection, anonymity, confidentiaity, and the aggregate nature of reporting. The reasons for staff suspicion concerning an externa survey of this nature are therefore uncear. Pure pays and hybrids: survey response differences responses diverged (by around 20 percentage points) on the foowing 12 items: y questions, their item % pure pays agree % hybrids agree 1 The amount of bureaucracy that I have to dea with has increased 60 84 Athough my roe incudes management responsibiities, I do not ike to be seen as a manager 9 29 I am cear about the requirements of my manageria roe 89 67 I am abe to exert infuence in my area of the organization 81 59 I am abe to exert infuence in other parts of the organization 67 40 I have received sufficient training for my management roe 74 43 I was given a choice as to whether or not I took on a management roe 79 50 Queen's Printer and Controer of HMSO 2013. 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. 169

APPENDIX 3 I often strugge to baance the priorities of both my manageria and cinica roes 24 56 I have a good knowed 84 65 I receive support for my manageria roe from my persona networks 70 50 I make decisions that directy affect the ives of patients 59 81 I fee mysef to be part of the organization 80 63 1. agg Hybrids thus appear on this evidence to be somewhat more reuctant to be described as managers, and ony haf indicated that they had a choice with regard to accepting this roe, compared with amost 80 percent of pure pays. In addition, hybrids in comparison with pure pays appear to: have more difficuty baancing manageria and cinica priorities (not surprising); have experienced more growth in the burden of bureaucracy; be ess cear about their mana be ess abe to exert infuence around the organization; ack management training, peer support, and a sense of organizationa beonging. These comparisons must be interpreted with caution for severa reasons. First, of the 611 respondents the survey questionnaire then proceeded to respond to a of the subsequent items. The tota number of responses from pure pays to each item ranged from 63 to102 (median number of responses 95), and for hybrids from 241 to 291 (median 275). The comparisons above are thus based on a sampe of approximatey 370 responses. Third, given the consequences of this response for average ce vaues, it is not appropriate to compare pure pay and hybrid survey responses across the five participating trusts. Finay, as chapter 2 expains, these are not ceary defined occupationa categories, as some cinica backgrounds (and may request that they be coded as such for NHS Information Centre census purposes). Nevertheess, these concusions are a in the expected directions, and reinforce the need for further management deveopment and support for hybrids, particuary with regard to infuencing skis and corporate communications. As other information gathered in the course of this study suggests, streamining bureaucracy woud benefit many acute trust staff, and not just hybrid managers. 170 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Respon Respondents were asked to identify which of thirteen categories of work their roes incuded (rather respondents who answered this question identified an average of two categories each, totaing 1,264. The foowing tabe first shows the numbers (and percentages) of respondents identifying each ot shows the cumuative frequency of the 1,264 responses in those thirteen categories. respondents responses work category nos % (of 612) cumuative n cumuative% (of 1,264) 1. management 261 43 261 21 2. admin and cerica* 200 33 461 36 3. project management 166 27 627 50 4. nursing 139 23 766 60 5. finance 96 16 862 68 6. research and deveopment 90 15 952 75 7. aied heath professiona 86 14 1,038 82 8. medica/surgica consutant 72 12 1,110 88 9. executive 47 8 1,157 92 10. estates and faciities 39 6 1,196 95 11. speciaty registrar 22 4 1,218 96 12. junior doctor 23 4 1,241 98 13. heath care assistant 23 4 1,264 100 * Observations 1. This survey drew respondents from a cross section of occupations and roes, from heathcare assistants and junior doctors, to midde and senior managers. As indicated in our previous do carry out manageria work, and this is refected in this response pattern. 2. Over two thirds (68 per cent) of responses fa into five categories of work: management, admin and cerica, project management, nursing, and finance. We cannot assume that a respondent identifying two categories devotes haf of their time to each; those proportions wi vary. However, this cacuation provides some insight into the profie of the sampe. Queen's Printer and Controer of HMSO 2013. 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. 171

APPENDIX 3 Trust comparisons The foowing chart compares the response patterns across the five trusts based on the percentages of respondents identifying each category of work: heath care assistant junior doctor speciaty registrar estates and facii es execu ve medica/surgica consutant aied heath professiona research and deveopment finance Cearview Burnside S Netey Netherby Greenhi nursing project management admin and cerica* management 0 10 20 30 40 50 60 70 80 * Observations 1. This shows that the wide cross-sectiona response was repeated at each of the five participating trusts, with broady simiar response patterns in each case. 2. Four ow proportion of consutants responding at Burnside, and the high proportions of consutants responding at Netherby, aong with project management and genera management respondents at Greenhi. As the project team had no direct contro over survey distribution, and were unabe to contact respondents directy, we have no expanation for these differences in response patterns. 172 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 How do they manage? a study of the reaities of midde and front ine management work in heathcare Management Survey 2011 Burnside This report shows the combined frequency distributions (in percentages) for 108 responses to the questions in this survey from Burnside Hospita. Many respondents did not answer a of the questions; for most items the tota response is around 80. The figures reported here show the percentages of those who did respond to each item. Emma Parry and David Buchanan: 10 March 2012 Queen's Printer and Controer of HMSO 2013. 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. 173

APPENDIX 3 Reaities of the job item strongy disagree neither agree or disagree strongy agree The need for me to focus on cost effectiveness has increased 1.3 1.3 5.1 30.4 62.0 ho is responsibe for what 3.8 24.1 25.3 34.2 12.7 The amount of bureaucracy that I need to dea with has increased The need for me to be more businessike (i.e. manage my department more ike a commercia organization) has increased The need for managers to use evidence- based interventions in their practice has increased The pressure for my department to meet targets has increased The expectation that cinica staff wi take on manageria roes has increased Athough my roe incudes management responsibiities, I do not ike to be seen as a manager I am cear about the requirements of my manageria roe 1.3 3.8 11.5 43.6 39.7 0.0 6.3 19.0 39.2 35.4 0.0 6.3 24.1 43.0 26.6 13.3 3.8 15.2 30.4 49.4 1.3 2.6 26.0 32.5 37.7 23.7 27.6 22.4 17.1 9.2 1.3 12.0 10.7 33.3 42.7 My overa workoad is usuay manageabe 15.4 39.7 7.7 28.2 9.0 I have enough time to compete a of my management duties I am abe to maintain a satisfactory work-ife baance I am abe to exert infuence in my area of the organization Other empoyees have negative attitudes towards this organization I am abe to exert infuence in other parts of the organization My management contribution is vaued by cinica staff 17.9 53.8 10.3 11.5 6.4 14.1 21.8 21.8 29.5 12.8 2.7 9.5 13.5 43.2 31.1 1.3 25.6 32.1 20.5 20.5 1.3 20.5 28.2 33.3 16.7 1.3 6.4 24.4 42.3 25.6 174 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agree I have the necessary authority to make management decisions at my eve I have received sufficient training for my management roe I was given a choice as to whether or not I took on a management roe I have a probem accepting management responsibiities Most cinica staff do not have the peope skis required to drive change I sometimes fee uncomfortabe managing my professiona peers I have sufficient resources to carry out my management responsibiities effectivey I often strugge to baance the priorities of both my manageria and cinica roes I have had to reduce my cinica work to fufi my management duties I fee resentfu of having to reduce my cinica responsibiities in order to undertake manageria work 2.6 15.4 16.7 39.7 25.6 5.3 20.0 20.0 33.3 21.3 10.1 14.5 23.2 29.0 23.2 49.4 31.6 6.3 6.3 6.3 6.8 24.3 31.1 24.3 13.5 17.9 32.1 21.8 19.2 9.0 9.0 39.7 12.8 28.2 10.3 8.3 11.7 23.3 20.0 36.7 4.8 21.0 32.3 17.7 24.2 5.0 28.3 38.3 16.7 11.7 objectives and pans It is easy for me to form good working reationships with coeagues In this organization I see eadership operating at a eves There are not many good manageria roe modes in this organization I receive support for my manageria roe from my persona networks 5.4 6.8 10.8 41.9 35.1 0.0 1.4 1.4 40.6 56.5 3.8 23.1 24.4 28.2 20.5 9.0 26.9 25.6 23.1 15.4 3.9 9.1 28.6 31.2 27.3 It is aways cear who is in charge of a situation 1.3 40.5 25.3 21.5 11.4 Queen's Printer and Controer of HMSO 2013. 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. 175

APPENDIX 3 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agree In my experience, managers fee empowered to take charge when they have something to offer I have reevant capabiities that I am not abe to use in my current position As the pressure on me increases, I have to pass the pressure on to the staff for whom I am responsibe It is becoming harder to motivate staff in the current cost-cutting cimate I have had to accept responsibiity for tasks that are beyond my ski and experience 6.4 16.7 29.5 43.6 3.8 2.7 22.7 29.3 25.3 20.0 3.9 18.2 27.3 33.8 16.9 1.3 18.4 13.2 44.7 22.4 12.8 28.2 33.3 20.5 5.1 We do not have good peer group support here 7.9 31.6 28.9 19.7 11.8 176 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Job characteristics item strongy disagree neither agree or disagree strongy agree job in this 4.0 17.3 25.3 32.0 21.3 0.0 9.0 16.0 42.7 32 My management responsibiities just seem to keep expanding 0.0 16.0 21.3 28.0 34.7 I am constanty expected to respond instanty 1.4 8.2 15.1 31.5 43.8 I am responsibe for showing ess experienced staff how to perform effectivey I frequenty arrive earier and/or eave ater than my contract requires I make decisions that directy affect the ives of patients 1.4 8.5 15.5 42.3 32.4 4.2 5.6 9.9 25.4 54.9 3.3 9.8 8.2 31.1 47.5 My priorities change every week 4.0 17.3 24.0 34.7 20.0 I am expected to improve the service we provide despite resources being cut A ot of my time is spent responding to requests for information, reports and action pans I have to get arge numbers of peope to agree even to make sma changes 4.2 1.4 2.8 29.6 62.0 2.8 7.0 15.5 35.2 39.4 2.7 15.1 23.3 35.6 23.3 in my job nd chaenge 16.2 32.4 31.1 12.2 8.1 0.0 9.6 20.5 45.2 24.7 In my job I get to work with high-caibre coeagues 0.0 4.2 25.0 41.7 29.2 I am we paid for what I do 5.4 20.3 32.4 31.1 10.8 I get recognition for my achievements in this job 8.1 31.1 24.3 23.0 13.5 I enjoy the power and status that I have in my roe 6.7 12.0 52.0 22.7 6.7 Queen's Printer and Controer of HMSO 2013. 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. 177

APPENDIX 3 Persona and organizationa outcomes item strongy disagree neither agree or disagree strongy agree I am motivated by deveoping other empoyees 0.0 4.1 2.7 50.7 42.5 My management roe aows me to make a difference to patient we being I am proud to be abe to te peope who it is I work for I sometimes fee ike eaving this empoyment for good 0.0 5.8 11.6 47.8 34.8 0.0 6.8 23.0 40.5 29.7 17.6 27.0 28.4 17.6 9.5 I woud not recommend a friend to join our staff 21.9 28.8 30.1 12.3 6.8 organization ef out just to hep the 55.4 27.0 10.8 4.1 2.7 In spite of financia pressures, I woud be reuctant to change to another empoyer 2.7 10.8 29.7 27.0 29.7 I fee mysef to be part of the organization 0.0 2.7 21.9 41.1 34.2 In my work I ike to fee I am making some effort, not just for mysef, but for the organization as we The offer of a bit more money with another empoyer woud not seriousy make me think of changing my job To know my own work had made a contribution to the good of the organization woud pease me Patient safety is never put at risk because of financia pressures It is sometimes inevitabe that patient safety is put at risk I have taken decisions that benefit patients, knowing that I have gone over budget as a resut It is often necessary to make a trade off between patient safety, quaity of care and financia targets 0.0 2.9 8.8 44.1 44.1 4.1 13.7 28.8 26.0 27.4 1.5 1.5 2.9 41.2 52.9 13.2 23.5 26.5 25.0 11.8 17.4 23.2 34.8 23.2 1.4 0.0 11.3 32.3 40.3 16.1 11.9 19.4 32.8 28.4 7.5 178 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Job satisfaction item very dissatisfied very satisfied Considering everything, how satisfied are you with your job? Considering everything, how woud you rate your overa satisfaction with your organization at the present time? 0.0 11.3 29.6 52.1 7.0 1.4 19.7 43.7 32.4 2.8 very poor very good How woud you rate this organization to work for compared to others? 1.4 8.1 47.3 35.1 8.1 Persona experience item never occasionay some of the time much of the time most of the time a of the time I worry about probems after work 1.4 13.5 37.8 24.3 20.3 2.7 I find it difficut to unwind after work 1.4 28.4 27.0 24.3 16.2 2.7 I fee used up after work 4.1 17.8 32.9 21.9 17.8 5.5 I fee exhausted after work 5.4 16.2 32.4 23.0 18.9 4.1 Survey items specific to Burnside item strongy disagree neither agree or disagree strongy agree Aside from appraisas, I get quaity time for one to one meetings with my ine manager One to one meetings incude management and eadership discussion, opportunities, refections My career and persona deveopment pan incudes eadership deveopment 11.1 16.7 13.9 29.2 29.2 12.7 14.1 22.5 28.2 22.5 11.3 22.5 29.6 12.7 23.9 Queen's Printer and Controer of HMSO 2013. 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. 179

APPENDIX 3 My idea eadership deveopment programme incudes: mapped against the seven domains of the NHS Leadership Framework (2011), as foows: are 1. Demonstrating persona quaities sef presentation sef awareness earning types time management (2) mora imperative emotiona inteigence 2. Working with others (three sub-categories) soft skis peope management how to deveop peope mentoring motivating others (2) appraisa training (2) deaing with difficut peope (2) confict management (2) acceptabe workpace behaviour deaing with staff in difficut situations teamwork team buiding team types more time to manage my team how to ead teams interpersona skis teamwork skis infuencing without necessariy having direct management responsibiities managing and infuencing staff infuencing others infuencing and negotiating negotiation skis (2) 3. Managing services (two sub-categories) advice on management manager management quaity issues patient safety patient experience resource management financia skis budgeting and finance budget management financia management in a changing environment (2) better understanding of financia income streams, tariffs genera management finance 180 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 4. Improving services performance management supporting and encouraging innovation innovations in practice project management (2) change management (4) motivating change cear systems for bringing in change 5. Setting direction management and eadership eadership skis eading through infuence 6. Creating the vision shared vision nationa drivers targets and drivers greater understanding of government initiatives and trust impementation 7. Deivering the strategy business acumen systems thinking trust issues and initiatives information on NHS financia workings networking with other organizations communication improved communication communication Queen's Printer and Controer of HMSO 2013. 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. 181

APPENDIX 3 Leadership programme process suggestions These suggestions fa into three broad categories concerning practica skis deveopment, the benefits of mentoring, shadowing and networking, and making adequate time aowance. practica skis deveopment and accreditation: earning sessions to deveop skis cinica supervision workshops hands on experience opportunity to deveop within the team rather than focus on individuas degree eve, recognized certificate studied at masters eve mentoring, shadowing, networking: forma training with mentor support chance to share experience with a mentor shadowing opportunities to shadow seconded work across the organization seconded work with partners and commissioners time for managing, studying, and sharing: freedom for cinica managers to manage their section for the benefit of patients reguar meetings with cinicians in simiar roes to discuss projects, share ideas, probem soving reguar meetings with junior staff to aid their eadership skis useess without the time factored in to do the MBA more time at work to study within my area of work not a ot of homework 182 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 How do they manage? a study of the reaities of midde and front ine management work in heathcare Management Survey 2011 Cearview This report shows the combined frequency distributions (in percentages) for the 250 responses to the questions in this survey from Cearview Hospita. Many respondents did not answer a of the questions; for most items the tota response is around 140. The figures reported here show the percentages of those who did respond to each item. Emma Parry and David Buchanan: 8 March 2012 Queen's Printer and Controer of HMSO 2013. 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. 183

APPENDIX 3 Reaities of the job item strongy disagree neither agree or disagree strongy agreee The need for me to focus on cost effectiveness has increased 7.4 1.5 7.4 22.1 61.8 ho is responsibe for what 4.4 19.9 19.1 41.9 14.7 The amount of bureaucracy that I need to dea with has increased The need for me to be more businessike (i.e. manage my department more ike a commercia organization) has increased The need for managers to use evidence- based interventions in their practice has increased The pressure for my department to meet targets has increased The expectation that cinica staff wi take on manageria roes has increased Athough my roe incudes management responsibiities, I do not ike to be seen as a manager I am cear about the requirements of my manageria roe 4.4 3.7 16.2 29.4 46.3 4.4 5.9 18.4 27.2 44.1 4.4 6.7 27.4 37.0 24.4 5.1 5.1 5.9 23.5 60.3 3.7 3.7 27.6 28.4 36.6 21.6 23.2 32.8 9.6 12.8 3.1 12.2 9.2 30.5 45.0 My overa workoad is usuay manageabe 21.5 33.3 10.4 25.2 9.6 I have enough time to compete a of my management duties I am abe to maintain a satisfactory work-ife baance I am abe to exert infuence in my area of the organization Other empoyees have negative attitudes towards this organization I am abe to exert infuence in other parts of the organiation My management contribution is vaued by cinica staff 28.1 36.3 10.4 19.3 5.9 19.3 20.7 17.8 28.9 13.3 9.1 14.4 11.4 35.6 29.5 0.8 16.5 23.3 36.1 23.3 20.5 18.9 19.7 31.1 9.8 4.8 11.3 30.6 37.1 16.1 184 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agreee I have the necessary authority to make management decisions at my eve I have received sufficient training for my management roe I was given a choice as to whether or not I took on a management roe I have a probem accepting management responsibiities Most cinica staff do not have the peope skis required to drive change I sometimes fee uncomfortabe managing my professiona peers I have sufficient resources to carry out my management responsibiities effectivey I often strugge to baance the priorities of both my manageria and cinica roes I have had to reduce my cinica work to fufi my management duties I fee resentfu of having to reduce my cinica responsibiities in order to undertake manageria work 9.2 15.3 10.7 38.9 26.0 4.5 19.5 25.6 32.3 18.0 8.2 15.6 13.9 25.4 36.9 59.5 25.2 9.9 2.3 3.1 16.9 21.8 36.3 16.9 8.1 26.6 25.8 17.7 23.4 6.5 16.4 36.6 19.4 20.9 6.7 4.1 22.4 23.5 27.6 22.4 12.4 22.5 22.5 21.3 21.3 8.3 27.4 34.5 19.0 10.7 objectives and pans It is easy for me to form good working reationships with coeagues In this organization I see eadership operating at a eves There are not many good manageria roe modes in this organization I receive support for my manageria roe from my persona networks 7.6 6.9 22.9 39.7 22.9 3.9 3.9 3.9 43.4 45.0 11.1 27.4 21.5 28.9 11.1 3.7 24.6 32.8 20.9 17.9 5.3 14.4 26.5 37.1 16.7 It is aways cear who is in charge of a situation 9.8 39.8 19.5 22.6 8.3 Queen's Printer and Controer of HMSO 2013. 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. 185

APPENDIX 3 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agreee In my experience, managers fee empowered to take charge when they have something to offer I have reevant capabiities that I am not abe to use in my current position As the pressure on me increases, I have to pass the pressure on to the staff for whom I am responsibe It is becoming harder to motivate staff in the current cost-cutting cimate I have had to accept responsibiity for tasks that are beyond my ski and experience 6.0 21.6 26.1 36.6 9.7 5.3 25.6 26.3 20.3 22.6 7.0 26.4 16.3 40.3 10.1 3.8 18.5 10.0 39.2 28.5 17.3 33.1 21.8 20.3 7.5 We do not have good peer group support here 11.2 26.9 22.4 21.6 17.9 186 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Job characteristics item strongy disagree neither agree or disagree strongy agreee job next in this 4.7 18.8 30.5 26.6 19.5 0.8 7.1 11.1 42.9 38.1 My management responsibiities just seem to keep expanding 0.0 8.7 17.5 43.7 30.2 I am constanty expected to respond instanty 0.0 7.1 19.0 37.3 36.5 I am responsibe for showing ess experienced staff how to perform effectivey I frequenty arrive earier and/or eave ater than my contract requires I make decisions that directy affect the ives of patients 0.8 4.8 10.3 43.7 40.5 3.2 5.6 9.6 28.0 53.6 8.1 5.1 13.1 26.3 47.5 My priorities change every week 2.4 17.5 22.2 34.9 23.0 I am expected to improve the service we provide despite resources being cut A ot of my time is spent responding to requests for information, reports and action pans I have to get arge numbers of peope to agree even to make sma changes 0.0 1.6 6.5 32.3 59.7 4.1 8.2 13.9 31.1 42.6 1.6 14.8 19.7 35.2 28.7 in my job tion and chaenge 16.7 30.2 23.0 23.8 6.3 3.1 11.7 10.9 37.5 36.7 In my job I get to work with high-caibre coeagues 1.6 14.3 15.9 34.9 33.3 I am we paid for what I do 20.5 15.0 25.2 23.6 15.7 I get recognition for my achievements in this job 19.7 19.7 19.7 29.9 11.0 I enjoy the power and status that I have in my roe 8.7 13.4 37.8 29.9 10.2 Queen's Printer and Controer of HMSO 2013. 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. 187

APPENDIX 3 Persona and organizationa outcomes item strongy disagree neither agree or disagree strongy agreee I am motivated by deveoping other empoyees 2.4 1.6 10.4 35.2 50.4 My management roe aows me to make a difference to patient we being I am proud to be abe to te peope who it is I work for I sometimes fee ike eaving this empoyment for good 2.7 6.2 14.2 46.9 30.1 1.6 8.1 21.8 30.6 37.9 23.2 17.6 18.4 26.4 14.4 I woud not recommend a friend to join our staff 33.3 32.5 18.3 11.1 4.8 organization In spite of financia pressures, I woud be reuctant to change to another empoyer 55.6 31.7 5.6 4.8 2.4 9.5 8.7 31.0 23.8 27.0 I fee mysef to be part of the organization 3.9 8.7 21.3 44.1 22.0 In my work I ike to fee I am making some effort, not just for mysef, but for the organization as we The offer of a bit more money with another empoyer woud not seriousy make me think of changing my job To know my own work had made a contribution to the good of the organization woud pease me Patient safety is never put at risk because of financia pressures It is sometimes inevitabe that patient safety is put at risk I have taken decisions that benefit patients, knowing that I have gone over budget as a resut It is often necessary to make a trade off between patient safety, quaity of care and financia targets 0.0 2.4 9.6 40.0 48.0 13.4 17.3 20.5 26.8 22.0 0.0 0.8 3.2 38.4 57.6 26.0 34.1 23.6 11.4 4.9 17.1 21.1 24.4 25.2 12.2 5.7 9.1 27.3 34.1 23.9 12.2 14.8 23.5 27.8 21.7 188 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Job satisfaction item very dissatisfied very satisfied Considering everything, how satisfied are you with your job? Considering everything, how woud you rate your overa satisfaction with your organization at the present time? 4.0 11.2 34.4 40.8 9.6 8.7 24.6 34.9 27.8 4.0 very poor very good How woud you rate this organization to work for compared to others? 2.4 15.2 42.4 28.0 12.0 Persona experience item never occasionay some of the time much of the time most of the time a of the time I worry about probems after work 1.6 19.7 30.7 22.8 22.0 3.1 I find it difficut to unwind after work 3.9 31.5 25.2 21.3 15.0 3.1 I fee used up after work 4.8 20.6 24.6 23.0 21.4 5.6 I fee exhausted after work 4.7 18.9 25.2 20.5 24.4 6.3 Queen's Printer and Controer of HMSO 2013. 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. 189

APPENDIX 3 How do they manage? a study of the reaities of midde and front ine management work in heathcare Management Survey 2011 Greenhi This report shows the combined frequency distributions (in percentages) for the 77 responses to the questions in this survey from Greenhi Hospita. Many respondents did not answer a of the questions; for most items the tota response is around 60. The figures reported here show the percentages of those who did respond to each item. At Greenhi, this survey was distributed ony to Emma Parry and David Buchanan: 8 March 2012 190 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Reaities of the job item strongy disagree neither agree or disagree strongy agree The need for me to focus on cost effectiveness has increased 0.0 7.0 0.0 24.6 68.4 sibe for what 7.0 24.6 15.8 35.1 17.5 The amount of bureaucracy that I need to dea with has increased The need for me to be more businessike (i.e. manage my department more ike a commercia organization) has increased The need for managers to use evidence- based interventions in their practice has increased The pressure for my department to meet targets has increased The expectation that cinica staff wi take on manageria roes has increased Athough my roe incudes management responsibiities, I do not ike to be seen as a manager I am cear about the requirements of my manageria roe 1.8 3.5 22.8 36.8 35.1 1.8 1.8 10.5 42.1 43.9 3.6 5.5 23.6 47.3 20.0 1.8 3.5 12.3 29.8 52.6 1.8 1.8 14.5 38.2 43.6 23.6 30.9 29.1 5.5 10.9 0.0 10.5 7.0 35.1 47.4 My overa workoad is usuay manageabe 15.8 40.4 10.5 21.1 12.3 I have enough time to compete a of my management duties I am abe to maintain a satisfactory work-ife baance I am abe to exert infuence in my area of the organization Other empoyees have negative attitudes towards this organization I am abe to exert infuence in other parts of the organization My management contribution is vaued by cinica staff 28.1 31.6 14.0 19.3 7.0 14.0 35.1 21.1 19.3 10.5 0.0 14.5 14.5 40.0 30.9 3.8 5.7 15.1 45.3 30.2 5.5 20.0 9.1 49.1 16.4 0.0 18.9 18.9 43.4 18.9 Queen's Printer and Controer of HMSO 2013. 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. 191

APPENDIX 3 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agree I have the necessary authority to make management decisions at my eve I have received sufficient training for my management roe I was given a choice as to whether or not I took on a management roe I have a probem accepting management responsibiities Most cinica staff do not have the peope skis required to drive change I sometimes fee uncomfortabe managing my professiona peers I have sufficient resources to carry out my management responsibiities effectivey I often strugge to baance the priorities of both my manageria and cinica roes I have had to reduce my cinica work to fufi my management duties I fee resentfu of having to reduce my cinica responsibiities in order to undertake manageria work 5.4 7.1 19.6 37.5 30.4 1.8 12.5 14.3 39.3 32.1 6.4 12.8 17.0 19.1 44.7 71.7 15.1 9.4 3.8 0.0 25.0 32.1 26.8 10.7 5.4 36.0 26.0 12.0 18.0 8.0 16.4 21.8 20.0 34.5 7.3 7.7 20.5 15.4 30.8 25.6 5.3 18.4 13.2 28.9 34.2 20.0 17.1 25.7 20.0 17.1 objectives and pans It is easy for me to form good working reationships with coeagues In this organization I see eadership operating at a eves There are not many good manageria roe modes in this organization I receive support for my manageria roe from my persona networks 1.9 1.9 5.7 41.5 49.1 1.9 1.9 3.7 50.0 42.6 5.5 29.1 20.0 30.9 14.5 16.4 29.1 25.5 14.5 14.5 7.4 5.6 16.7 40.7 29.6 It is aways cear who is in charge of a situation 14.5 36.4 16.4 27.3 5.5 192 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agree In my experience, managers fee empowered to take charge when they have something to offer I have reevant capabiities that I am not abe to use in my current position As the pressure on me increases, I have to pass the pressure on to the staff for whom I am responsibe It is becoming harder to motivate staff in the current cost-cutting cimate I have had to accept responsibiity for tasks that are beyond my ski and experience 7.3 20.0 30.9 29.1 12.7 5.8 26.9 25.0 19.2 23.1 7.3 10.9 23.6 43.6 14.5 0.0 18.9 5.7 37.7 37.7 16.4 41.8 16.4 14.5 10.9 We do not have good peer group support here 21.4 32.1 16.1 21.4 8.9 Queen's Printer and Controer of HMSO 2013. 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. 193

APPENDIX 3 Job characteristics item strongy disagree neither agree or disagree strongy agree job 7.4 7.4 27.8 33.3 24.1 0.0 0.0 5.6 57.4 37.0 My management responsibiities just seem to keep expanding 0.0 13.0 18.5 35.2 33.3 I am constanty expected to respond instanty 0.0 7.4 7.4 38.9 46.3 I am responsibe for showing ess experienced staff how to perform effectivey I frequenty arrive earier and/or eave ater than my contract requires I make decisions that directy affect the ives of patients 0.0 5.6 16.7 48.1 29.6 0.0 10.2 8.2 8.2 73.5 10.0 2.5 12.5 42.5 32.5 My priorities change every week 5.7 11.3 30.2 28.3 24.5 I am expected to improve the service we provide despite resources being cut A ot of my time is spent responding to requests for information, reports and action pans I have to get arge numbers of peope to agree even to make sma changes 0.0 2.0 4.0 24.0 70.0 1.9 7.5 13.2 35.8 41.5 5.8 7.7 9.6 40.4 36.5 11.3 24.5 28.3 22.6 13.2 in my job In my job I get to work with high-caibre coeagues 3.7 13.0 9.3 42.6 31.5 1.9 13.0 14.8 37.0 33.3 I am we paid for what I do 5.7 9.4 18.9 45.3 20.8 I get recognition for my achievements in this job 3.7 29.6 20.4 27.8 18.5 I enjoy the power and status that I have in my roe 7.4 9.3 35.2 37.0 11.1 194 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Persona and organizationa outcomes item strongy disagree neither agree or disagree strongy agree I am motivated by deveoping other empoyees 0.0 1.9 1.9 43.4 52.8 My management roe aows me to make a difference to patient we being I am proud to be abe to te peope who it is I work for I sometimes fee ike eaving this empoyment for good 0.0 5.9 13.7 43.1 37.3 1.9 11.3 22.6 34.0 30.2 22.6 17.0 9.4 34.0 17.0 I woud not recommend a friend to join our staff 28.3 26.4 26.4 9.4 9.4 organization ef out just to hep the 49.1 43.4 5.7 0.0 1.3 In spite of financia pressures, I woud be reuctant to change to another empoyer 9.4 13.2 17.0 30.2 30.2 I fee mysef to be part of the organization 1.9 7.5 17.0 35.8 37.7 In my work I ike to fee I am making some effort, not just for mysef, but for the organization as we The offer of a bit more money with another empoyer woud not seriousy make me think of changing my job To know my own work had made a contribution to the good of the organization woud pease me Patient safety is never put at risk because of financia pressures It is sometimes inevitabe that patient safety is put at risk I have taken decisions that benefit patients, knowing that I have gone over budget as a resut It is often necessary to make a trade off between patient safety, quaity of care and financia targets 1.9 1.9 0.0 36.5 59.6 9.4 17.0 24.5 28.3 20.8 0.0 3.9 2.0 27.5 66.7 16.0 38.0 28.0 12.0 6.0 6.1 20.4 22.4 49.0 2.0 4.5 6.8 9.1 38.6 40.9 14.6 10.4 10.4 37.5 27.1 Queen's Printer and Controer of HMSO 2013. 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. 195

APPENDIX 3 Job satisfaction item very dissatisfied very satisfied Considering everything, how satisfied are you with your job? Considering everything, how woud you rate your overa satisfaction with your organization at the present time? 7.5 9.4 34.0 35.8 13.2 9.4 28.3 34.0 28.0 7.5 very poor very good How woud you rate this organization to work for compared to others? 1.9 15.1 34.0 37.7 11.3 Persona experience item never occasionay some of the time much of the time most of the time a of the time I worry about probems after work 1.9 17.0 35.8 24.5 17.0 3.8 I find it difficut to unwind after work 5.7 28.3 20.8 28.3 17.0 0.0 I fee used up after work 5.7 9.4 22.6 28.3 32.1 1.9 I fee exhausted after work 1.9 15.1 28.3 22.6 30.2 1.9 196 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 How do they manage? a study of the reaities of midde and front ine management work in heathcare Management Survey 2011 Netherby This report shows the combined frequency distributions (in percentages) for the 86 responses to the questions in this survey from Netherby Hospita. Many respondents did not answer a of the questions; for most items the tota response is around 60. The figures reported here show the percentages of those who did respond to each item. Emma Parry and David Buchanan: 8 March 2012 Queen's Printer and Controer of HMSO 2013. 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. 197

APPENDIX 3 Reaities of the job item strongy disagree neither agree or disagree strongy agree The need for me to focus on cost effectiveness has increased 3.4 1.7 8.6 32.8 53.4 0.0 8.6 19.0 32.8 39.7 The amount of bureaucracy that I need to dea with has increased The need for me to be more businessike (i.e. manage my department more ike a commercia organization) has increased The need for managers to use evidence- based interventions in their practice has increased The pressure for my department to meet targets has increased The expectation that cinica staff wi take on manageria roes has increased Athough my roe incudes management responsibiities, I do not ike to be seen as a manager I am cear about the requirements of my manageria roe 0.0 1.7 19.0 22.4 56.9 0.0 5.2 10.3 37.9 46.6 5.2 10.3 34.5 20.7 29.3 3.4 0.0 12.1 20.7 63.8 3.4 1.7 12.1 41.4 41.4 10.3 25.9 24.1 19.0 20.7 13.0 24.1 13.0 33.3 16.7 My overa workoad is usuay manageabe 32.8 29.3 17.2 19.0 1.7 I have enough time to compete a of my management duties I am abe to maintain a satisfactory work-ife baance I am abe to exert infuence in my area of the organization Other empoyees have negative attitudes towards this organization I am abe to exert infuence in other parts of the organization My management contribution is vaued by cinica staff 38.6 40.4 8.8 12.3 0.0 27.6 32.8 15.5 17.2 6.9 14.0 26.3 14.0 31.6 14.0 7.3 9.1 16.4 30.9 36.4 17.5 19.3 24.6 29.8 8.8 8.8 14.0 28.1 36.8 12.3 198 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agree I have the necessary authority to make management decisions at my eve I have received sufficient training for my management roe I was given a choice as to whether or not I took on a management roe I have a probem accepting management responsibiities Most cinica staff do not have the peope skis required to drive change I sometimes fee uncomfortabe managing my professiona peers I have sufficient resources to carry out my management responsibiities effectivey I often strugge to baance the priorities of both my manageria and cinica roes I have had to reduce my cinica work to fufi my management duties I fee resentfu of having to reduce my cinica responsibiities in order to undertake manageria work I have a good knowedge objectives and pans It is easy for me to form good working reationships with coeagues In this organization I see eadership operating at a eves There are not many good manageria roe modes in this organization I receive support for my manageria roe from my persona networks 15.5 15.5 20.7 31.0 17.2 21.4 25.0 26.8 12.5 14.3 16.4 21.8 25.5 10.9 25.5 31.6 33.3 26.3 3.5 5.3 19.3 29.8 24.6 12.3 14.0 5.3 31.6 22.8 33.3 7.0 20.7 44.8 15.5 17.2 1.7 4.5 11.4 29.5 25.0 29.5 14.9 29.8 29.8 19.1 6.4 11.6 11.6 55.8 11.6 9.3 8.8 15.8 26.3 29.8 19.3 5.4 1.8 8.9 48.2 35.7 17.2 31.0 27.6 19.0 5.2 3.5 19.3 21.1 38.6 17.5 8.8 17.5 36.8 24.6 12.3 It is aways cear who is in charge of a situation 15.5 34.5 36.2 10.3 3.4 Queen's Printer and Controer of HMSO 2013. 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. 199

APPENDIX 3 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agree In my experience, managers fee empowered to take charge when they have something to offer I have reevant capabiities that I am not abe to use in my current position As the pressure on me increases, I have to pass the pressure on to the staff for whom I am responsibe It is becoming harder to motivate staff in the current cost-cutting cimate I have had to accept responsibiity for tasks that are beyond my ski and experience 5.3 17.5 47.4 24.6 5.3 7.0 7.0 35.1 29.8 21.1 10.7 30.4 16.1 28.6 14.3 0.0 5.5 18.2 29.1 47.3 10.5 26.3 31.6 19.3 12.3 We do not have good peer group support here 5.3 22.8 33.3 22.8 15.8 200 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Job characteristics item strongy disagree neither agree or disagree strongy agree job 0.0 17.5 21.1 29.8 31.6 0.0 10.5 15.8 33.3 40.4 My management responsibiities just seem to keep expanding 0.0 10.5 33.3 26.3 29.8 I am constanty expected to respond instanty 0.0 5.4 14.3 39.3 41.1 I am responsibe for showing ess experienced staff how to perform effectivey I frequenty arrive earier and/or eave ater than my contract requires I make decisions that directy affect the ives of patients 0.0 11.1 25.9 37.0 25.9 1.8 3.6 10.9 12.7 70.9 5.8 7.7 5.8 15.4 65.4 My priorities change every week 5.4 16.1 28.6 23.2 26.8 I am expected to improve the service we provide despite resources being cut A ot of my time is spent responding to requests for information, reports and action pans I have to get arge numbers of peope to agree even to make sma changes 1.8 0.0 7.1 23.2 67.9 1.8 7.1 16.1 33.9 41.1 1.9 7.4 18.5 33.3 38.9 hat I do, it is never good enough 10.5 21.1 22.8 21.1 24.6 in my job In my job I get to work with high-caibre coeagues 7.0 12.3 24.6 29.8 26.3 5.3 10.5 28.1 33.3 22.8 I am we paid for what I do 12.3 10.5 22.8 45.6 8.8 I get recognition for my achievements in this job 15.8 24.6 31.6 22.8 5.3 I enjoy the power and status that I have in my roe 14.0 19.3 45.6 19.3 1.8 Queen's Printer and Controer of HMSO 2013. 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. 201

APPENDIX 3 Persona and organizationa outcomes item strongy disagree neither agree or disagree strongy agree I am motivated by deveoping other empoyees 0.0 0.0 7.3 58.2 34.5 My management roe aows me to make a difference to patient we being I am proud to be abe to te peope who it is I work for I sometimes fee ike eaving this empoyment for good 1.9 7.5 30.2 34.0 26.4 5.3 15.8 29.8 33.3 15.8 12.5 17.9 21.4 23.2 25.0 I woud not recommend a friend to join our staff 19.6 25.0 26.8 12.5 16.1 organization ef out just to hep the 47.4 33.3 12.3 5.3 1.8 In spite of financia pressures, I woud be reuctant to change to another empoyer 12.5 10.7 41.1 17.9 17.9 I fee mysef to be part of the organization 10.5 22.8 19.3 24.6 22.8 In my work I ike to fee I am making some effort, not just for mysef, but for the organization as we The offer of a bit more money with another empoyer woud not seriousy make me think of changing my job To know my own work had made a contribution to the good of the organization woud pease me Patient safety is never put at risk because of financia pressures It is sometimes inevitabe that patient safety is put at risk I have taken decisions that benefit patients, knowing that I have gone over budget as a resut It is often necessary to make a trade off between patient safety, quaity of care and financia targets 0.0 1.8 21.1 31.6 45.6 10.5 15.8 28.1 21.1 24.6 0.0 0.0 11.1 35.2 53.7 31.6 29.8 19.3 12.3 7.0 17.9 14.3 25.0 26.8 16.1 2.1 4.2 29.2 31.3 33.3 11.3 7.5 17.0 45.3 18.9 202 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Job satisfaction item very dissatisfied very satisfied Considering everything, how satisfied are you with your job? Considering everything, how woud you rate your overa satisfaction with your organization at the present time? 10.7 25.0 26.8 33.9 3.6 21.8 36.4 32.7 9.1 0.0 very poor very good How woud you rate this organization to work for compared to others? 8.9 23.2 46.4 21.4 0.0 Persona experience item never occasionay some of the time much of the time most of the time a of the time I worry about probems after work 1.8 10.5 36.8 15.8 21.1 14.0 I find it difficut to unwind after work 0.0 21.4 35.7 12.5 16.1 14.3 I fee used up after work 0.0 15.8 22.8 21.1 26.3 14.0 I fee exhausted after work 0.0 16.1 25.0 19.6 21.4 17.9 Queen's Printer and Controer of HMSO 2013. 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. 203

APPENDIX 3 How do they manage? a study of the reaities of midde and front ine management work in heathcare Management Survey 2011 South Netey This report shows the combined frequency distributions (in percentages) for the 90 responses to the questions in this survey from South Netey Hospita. Many respondents did not answer a of the questions; for most items the tota response is around 60. The figures reported here show the percentages of those who did respond to each item. Emma Parry and David Buchanan: 8 March 2012 204 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Reaities of the job item strongy disagree neither agree or disagree strongy agree The need for me to focus on cost effectiveness has increased 4.5 3.0 6.0 14.9 71.6 4.5 16.7 24.2 31.8 22.7 The amount of bureaucracy that I need to dea with has increased The need for me to be more businessike (i.e. manage my department more ike a commercia organization) has increased The need for managers to use evidence- based interventions in their practice has increased The pressure for my department to meet targets has increased The expectation that cinica staff wi take on manageria roes has increased Athough my roe incudes management responsibiities, I do not ike to be seen as a manager I am cear about the requirements of my manageria roe 1.5 9.0 11.5 38.8 38.8 1.5 6.0 10.4 40.3 41.8 3.0 6.0 11.9 52.2 26.9 4.5 1.5 9.0 31.3 53.7 1.5 7.6 24.2 24.2 42.4 31.3 32.8 20.3 9.4 6.3 6.1 12.1 7.6 22.7 51.5 My overa workoad is usuay manageabe 28.8 34.8 13.6 16.7 6.1 I have enough time to compete a of my management duties I am abe to maintain a satisfactory work-ife baance I am abe to exert infuence in my area of the organization Other empoyees have negative attitudes towards this organization I am abe to exert infuence in other parts of the organization My management contribution is vaued by cinica staff 39.4 31.8 9.1 15.2 4.5 24.2 34.8 19.7 13.6 7.6 6.1 10.6 18.2 37.9 27.3 0.0 7.7 24.6 35.4 32.3 12.3 15.4 29.2 32.3 10.8 3.1 7.8 20.3 43.8 25.0 Queen's Printer and Controer of HMSO 2013. 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. 205

APPENDIX 3 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agree I have the necessary authority to make management decisions at my eve I have received sufficient training for my management roe I was given a choice as to whether or not I took on a management roe I have a probem accepting management responsibiities Most cinica staff do not have the peope skis required to drive change I sometimes fee uncomfortabe managing my professiona peers I have sufficient resources to carry out my management responsibiities effectivey I often strugge to baance the priorities of both my manageria and cinica roes I have had to reduce my cinica work to fufi my management duties I fee resentfu of having to reduce my cinica responsibiities in order to undertake manageria work 4.6 18.5 10.8 32.3 33.8 7.8 21.9 18.8 25.0 26.6 5.6 13.0 20.4 25.9 35.2 56.9 26.2 7.7 6.2 3.1 19.0 36.5 23.8 12.7 7.9 36.2 31.0 12.1 19.0 1.7 20.6 33.3 22.2 11.1 12.7 10.8 10.8 27.0 18.9 32.4 10.0 7.5 27.5 32.5 22.5 10.5 18.4 36.8 23.7 10.5 objectives and pans It is easy for me to form good working reationships with coeagues In this organization I see eadership operating at a eves There are not many good manageria roe modes in this organization I receive support for my manageria roe from my persona networks 3.1 6.2 12.3 40.0 38.5 1.7 3.3 3.3 38.3 53.3 9.1 12.1 21.2 31.8 25.8 9.2 24.6 33.8 12.3 20.0 4.8 12.7 25.4 38.1 19.0 It is aways cear who is in charge of a situation 12.3 36.9 26.2 18.5 6.2 206 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Reaities of the job (continued) item strongy disagree neither agree or disagree strongy agree In my experience, managers fee empowered to take charge when they have something to offer I have reevant capabiities that I am not abe to use in my current position As the pressure on me increases, I have to pass the pressure on to the staff for whom I am responsibe It is becoming harder to motivate staff in the current cost-cutting cimate I have had to accept responsibiity for tasks that are beyond my ski and experience 3.0 27.3 30.3 31.8 7.6 12.7 17.5 27.0 20.6 22.2 14.3 15.9 15.9 39.7 14.3 6.3 6.3 12.7 34.9 39.7 15.4 33.8 16.9 21.5 12.3 We do not have good peer group support here 14.1 35.9 12.5 21.9 15.6 Queen's Printer and Controer of HMSO 2013. 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. 207

APPENDIX 3 Job characteristics item strongy disagree neither agree or disagree strongy agree job 1.6 22.2 14.3 31.7 30.2 1.6 6.3 6.3 31.7 54.0 My management responsibiities just seem to keep expanding 0.0 9.5 19.0 30.2 41.3 I am constanty expected to respond instanty 1.6 11.1 14.3 28.6 44.4 I am responsibe for showing ess experienced staff how to perform effectivey I frequenty arrive earier and/or eave ater than my contract requires I make decisions that directy affect the ives of patients 0.0 7.9 7.9 44.4 39.7 3.3 1.6 6.6 21.3 67.2 4.2 8.3 12.5 20.8 54.2 My priorities change every week 3.2 12.7 12.7 33.3 38.1 I am expected to improve the service we provide despite resources being cut A ot of my time is spent responding to requests for information, reports and action pans I have to get arge numbers of peope to agree even to make sma changes 1.7 1.7 1.7 21.7 73.3 1.6 4.8 12.7 41.3 39.7 3.2 9.7 21.0 30.6 35.5 17.5 28.6 22.2 17.5 14.3 in my job In my job I get to work with high-caibre coeagues 3.2 9.7 12.9 33.9 40.3 4.8 6.5 16.1 37.1 35.5 I am we paid for what I do 11.3 9.7 20.9 33.9 16.1 I get recognition for my achievements in this job 17.7 14.5 21.0 31.6 16.1 I enjoy the power and status that I have in my roe 7.9 12.7 38.1 31.7 9.5 208 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Persona and organizationa outcomes item strongy disagree neither agree or disagree strongy agree I am motivated by deveoping other empoyees 0.0 6.3 7.9 31.7 54.0 My management roe aows me to make a difference to patient we being I am proud to be abe to te peope who it is I work for I sometimes fee ike eaving this empoyment for good 1.8 3.5 26.3 28.1 40.4 4.8 9.5 17.5 38.1 30.2 19.4 17.7 16.1 32.3 14.5 I woud not recommend a friend to join our staff 27.0 23.8 34.9 11.1 3.2 organization ef out just to hep the 53.2 30.6 11.3 3.2 1.6 In spite of financia pressures, I woud be reuctant to change to another empoyer 6.3 11.1 27.0 30.2 25.4 I fee mysef to be part of the organization 6.3 3.2 15.9 44.4 30.2 In my work I ike to fee I am making some effort, not just for mysef, but for the organization as we The offer of a bit more money with another empoyer woud not seriousy make me think of changing my job To know my own work had made a contribution to the good of the organization woud pease me Patient safety is never put at risk because of financia pressures It is sometimes inevitabe that patient safety is put at risk I have taken decisions that benefit patients, knowing that I have gone over budget as a resut It is often necessary to make a trade off between patient safety, quaity of care and financia targets 3.2 0.0 6.5 45.2 45.2 6.3 17.5 23.8 27.0 25.4 1.6 0.0 1.6 38.7 58.1 20.0 33.3 20.0 16.7 10.0 16.9 18.6 27.1 27.1 10.2 4.2 12.5 25.0 39.6 18.8 15.5 17.2 17.2 32.8 17.2 Queen's Printer and Controer of HMSO 2013. 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. 209

APPENDIX 3 Job satisfaction item very dissatisfied very satisfied Considering everything, how satisfied are you with your job? Considering everything, how woud you rate your overa satisfaction with your organization at the present time? 6.3 9.5 34.9 36.5 12.7 11.1 17.5 44.4 15.9 11.1 very poor very good How woud you rate this organization to work for compared to others? 6.3 7.9 52.4 22.2 11.1 Persona experience item never occasionay some of the time much of the time most of the time a of the time I worry about probems after work 1.6 7.9 31.7 27.0 23.8 7.9 I find it difficut to unwind after work 3.2 15.9 33.3 17.5 19.0 11.1 I fee used up after work 3.2 17.5 22.2 20.6 22.2 14.3 I fee exhausted after work 6.3 19.0 17.5 15.9 22.2 19.0 210 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Survey items specific to South Netey item strongy disagree neither agree or disagree strongy agree to my team 3.2 9.7 14.5 38.7 33.9 I am cear what is expected of me as a trust eader 4.8 4.8 14.5 43.5 32.3 In my management roe, my immediate manager heps me find a good work-ife baance My ine manager tries to invove me in important decisions 14.5 19.4 27.4 30.6 8.1 7.9 11.1 11.1 39.7 30.2 My work-ife baance is about right 20.6 23.8 30.2 20.6 4.8 The eve of communication between me and my manager is effective 7.9 19.0 6.3 38.1 28.6 I fee supported by trust senior management 20.6 12.7 28.6 23.8 14.3 4.8 6.3 9.5 44.4 34.9 I woud rather work at this trust than somewhere ese I have confidence that this trust wi achieve and succeed as a foundation trust 4.8 6.3 39.7 28.6 20.6 1.6 6.3 30.2 41.3 20.6 The future at this trust excites me 7.9 6.3 33.3 25.4 27.0 I am fairy remunerated for the work I do 4.8 19.0 23.8 30.2 22.2 I am proud to say I work at this trust 1.6 8.1 30.6 35.5 24.2 This trust toerates under-performers 11.3 22.6 21.0 30.6 14.5 This trust is a high performing organization 4.8 12.7 31.7 36.5 14.3 I fee respected by my team 0.0 1.6 6.5 48.4 43.5 I have a supportive and productive reationship with my peers 1.6 1.6 9.7 61.3 25.8 Queen's Printer and Controer of HMSO 2013. 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. 211

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Appendix 4 Managing the norovirus outbreak at Watte Park Main concusions 1. Watte Park had previous experience of norovirus (the winter vomiting bug), but this incident was on a much arger scae and the hospita appears to have been unprepared to hande it. 2. As this incident was different in scae and consequences from previous outbreaks, this was a significant earning opportunity with regard to future infection management procedures. 3. The invovement of two externa agencies potentiay exacerbated the impact of this outbreak, hastening decisions to cose wards and to withdraw service provision. 4. Initiay defined as a serious outbreak of norovirus, this incident quicky morphed to become a serious interruption of emergency and eective services. 5. Changes in the aftermath of this incident focused on hygiene procedures that were not picked up in the recommendations of the externa review; these procedures were within the contro of midde management, whereas costy changes to ageing faciities were not. 6. Changes in the aftermath of incidents ike this are shaped by the context in which the incident occurred, and in this case by the financia and oca poitica conditions facing this hospita, and by the differing views and priorities of the two externa agencies invoved. Introduction In January 2010 there was a major outbreak of norovirus (the winter vomiting bug) at Watte Park. Unike previous outbreaks, the number of cases rose rapidy, and within a few weeks a but four of the hospita's 33 wards were cosed to new admissions. The hospita was aso cosed to emergency admissions for 96 hours, and inpatient eective surgery was canceed for 5 weeks. Once the outbreak was under contro, an externa review into the causes was commissioned. This review identified a number of contributory factors concerning infection contro procedures, ward ceaning and the ayout and condition of the hospita estate. Recommendations thus invoved changes to infection contro procedures, most notaby ward cosure, and isoation of suspected cases; the ceaning arrangements foowing a ward cosure; increase in size and ski mix of the infection contro team; and more rapid confirmation of cases through on-site testing. One year ater, severa changes had been made. However, in a number of areas, recommendations had not been impemented. No changes had been made to the infection contro team and, because of financia constraints, ony imited changes had been made to the premises, thereby imiting the opportunity for isoation of suspected cases. There had aso been considerabe focus on hand hygiene foowing the outbreak, athough this had not been mentioned in the report, and the hospita had a good record in reation to MRSA and C. difficie. Senior managers aso questioned the definition of this incident: was this the contro of the virus, or the inabiity to provide emergency and other services? This case report concudes that the focus of activity foowing the outbreak was infuenced in part by the hospita's context, and in particuar the financia position, and the poitica context in which the externa review was received. After an event ike this, there is a perception of the need for urgent change. But what takes pace in the aftermath needs to be seen in the context in which the incident occurred, the investigation took pace and the report was received, particuary in reation to directing energy for change. Assessing the progress in impementing the recommendations from the review 1 year after the outbreak, some of the focus for change was on activities not mentioned in the recommendations, notaby on hand hygiene and cinica practice. This is puzzing. Given the serious nature and consequences of the outbreak, attention might have been expected to focus on the recommendations, particuary as the Queen's Printer and Controer of HMSO 2013. 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. 213

APPENDIX 4 report was competed rapidy foowing containment of the outbreak. However, the focus of activity and the widening of the discourse concerning necessary change were shaped by contextua factors, incuding the financia position of the trust, how the report was disseminated and perceptions of the findings. The report was not widey circuated to hospita staff. Severa senior nursing staff said that they had not seen it. This was in part because the initia draft was not we received by the executive team and modifications were requested. The outbreak and its consequences generated strong emotiona responses from staff, particuary nurses. It may have been the case that managers, not fuy aware of the recommendations, focused efforts on genera infection contro, even though this had not been specificay highighted by the review. The trust's severey constrained financia situation meant that it was difficut to respond fuy in the short term to recommendations invoving investment. Faced with this constraint, and the pressures to be seen to be doing something foowing an incident of this nature, the resut may have been a focus on activity overty inked to infection contro, invoving itte or no cost. Furthermore, decisions concerning the aocation of resources in this area were beyond the contro of managers such as ead nurses, who coud not authorise the creation of isoation bays, but were abe to persuade coeagues to wash their hands between each patient episode. The outbreak At the beginning of 2010, Watte Park experienced a serious outbreak of norovirus. This spread quicky, affecting many inpatient wards over severa weeks. At the peak of the outbreak, a but four of the hospita's wards were cosed to new admissions for about 1 month. This situation compromised the hospita's abiity to provide services to the oca community. Schedued eective in-patient procedures were canceed over 5 weeks, resuting in an estimated oss of income of around 6M. Emergency admissions were aso cosed for 96 hours and the hospita was in major incident mode for 5 weeks. For some of this time, to reduce the ikeihood of the virus being brought in from the community, access to the hospita was controed by security guards and inpatients were not aowed visitors for a period of 3 weeks. There had been severa previous outbreaks of norovirus at this hospita, but none had been as serious as this. In the past, the procedures in pace successfuy controed the spread of infection, with minor impact on service deivery. However, the experience on this occasion was different, and the Director of Infection Prevention and Contro (DIPC) admitted that, in spite of the externa investigation, it was not entirey cear why the virus had spread so rapidy this time. Information sources The information for this case study was coected in eary 2011, around 12 months after the start of the outbreak. This invoved semistructured interviews with eight hospita staff and access to hospita board papers, incuding the investigation report. Loca press reports were aso consuted. Interviewees refected different roes and eves of seniority, incuding two board directors, two operationa managers, two cinica staff and two staff with infection contro responsibiities. Interviews asted around 1 hour and were conducted in the hospita, in working time. With prior permission, interviews were audio recorded and subsequenty transcribed for anaysis. Board papers and press reports were subject to content anaysis. 214 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Organisationa context Watte Park is a teaching hospita offering a fu range of services, with an emergency department and urgent care centre, with 700 beds, 3400 staff and a budget of 240M in 2010 11. The trust had faced financia difficuties for severa years. In 2006 7, a surviva strategy was designed to address a deficit of 25M, and over 250 posts were ost foowing a recruitment freeze. Training budgets were aso reduced. Many managers described the rather crude approach that was used at that time as sash and burn, some indicating that they fet that the trust had thrown the baby out with the bathwater. Severa managers said that the hospita was sti suffering from the remaining scars. Watte Park was sti facing cost pressures at the time of this study, compounded by deficits among oca commissioners. Athough the position became more secure in 2011, staff were batte weary. There was uncertainty over the hospita's future roe with proposas to reorganise services in the area, and Watte Park was considering merging with other nearby trusts. It was fet that the hospita woud survive, and continue to provide emergency, maternity and reated services, but it was uncear which other services the hospita woud retain. Much of the hospita was housed in Victorian buidings that had been atered over the years. Most of the medica wards were in the oder areas and were traditiona Nightingae wards. Less than 10% of the hospita's beds were in singe rooms, and none of those rooms on the medica wards had en suite faciities. There was an isoation unit with nine singe rooms and two bays with three and four beds each respectivey. Ony one singe room in this unit had en suite faciities. Incident background The symptoms of norovirus incude nausea, projectie vomiting and diarrhoea. The virus is easiy spread from one person to another by the aerosos of projectie vomit and through faeca ora contamination. The infectious dose of the virus is ow and immunity tends to ast for ony a few weeks. Peope of a ages are susceptibe. Not a of those who are infected, however, exhibit a of the symptoms and, without testing, accurate diagnosis is difficut. Furthermore, the symptoms of norovirus are common to some other conditions. Athough this virus is not considered to be serious in heathy individuas, and recovery typicay takes ony 2 or 3 days, it may be more serious for those with existing conditions who may take much onger to recover. The virus is excreted for 48 hours after symptoms have stopped, but may inger for severa weeks. The outbreak began on Friday 8 January 2010 when a case of diarrhoea and vomiting (D&V) was reported to the infection contro team in one of the medica wards. The team then found that six patients on this ward had symptoms. Given the conditions of these patients, the DIPC thought that some of these symptoms might derive from other non-infectious causes and decided to pace this ward under surveiance. Restrictions were paced on moving patients out of this ward, but not on new admissions. The ward was reviewed over the weekend, when further cases of D&V were identified, but the ward remained under surveiance and was not cosed to new admissions. On Sunday 10 January, two more medica wards reported patients with D&V symptoms. One of these wards was subsequenty cosed to new admissions whie the other was paced under surveiance, as it was fet that the symptoms were unikey to be caused by a norovirus infection. On Monday 11 January, the hospita formay decared a norovirus outbreak and informed the Heath Protection Agency (HPA) and commissioners. The wards under surveiance were cosed to new admissions and daiy outbreak meetings were instituted to contro the spread of the virus. Over the foowing 5 days, more wards reported patients with symptoms, and these were assessed by the infection contro team. More wards were cosed to new admissions unti a patients in the ward had been symptom free for at east 48 hours. Queen's Printer and Controer of HMSO 2013. 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. 215

APPENDIX 4 On Tuesday 12 January, the hospita decared a Sustained Ongoing Interna Major Incident, and from Wednesday 13 January, for 5 weeks, a eective inpatient admissions were canceed. From 25 to 29 January the hospita cosed to emergency admissions for 96 hours to avoid admitting any more infected patients from the community. From 26 January, the Bronze Contro Team was based in the hospita boardroom, deaing with operationa decision-making and communications and providing support to the infection contro team. Additiona speciaist infection contro nurses were seconded from neighbouring hospitas. Foowing a meeting of hospita management with their commissioners and the HPA, a more risk-averse approach to cosing wards to new admissions was adopted. It was agreed that reported cases woud be assumed to be norovirus uness proven otherwise, and wards woud be cosed to new admissions when ward staff reported two or more patients with D&V symptoms. Previousy, the poicy had been to reopen wards 48 hours after the ast symptoms had been observed. This was now changed to 72 hours, in ine with HPA guideines. There was conficting opinion about the progress of the outbreak. The DIPC said that he beieved that the outbreak was coming to an end by 18 January, when the number of new cases reported was ony three, athough there was a high number of ongoing cases. This was in ine with the hospita's previous experience of abeit more imited outbreaks. Investigation Foowing the incident, an externa review was jointy commissioned by the hospita and its main commissioning body. The investigation report was deivered in a reativey short period of time and a first draft was avaiabe in February 2010. The review was conducted by an infection contro professiona from a hospita in another area. This review argey invoved conversations with senior managers and the infection contro team. The resutant report highighted a number of shortcomings. Overa, there had been a faiure on the wards to recognise the symptoms of the virus and to report these to the infection contro team at an eary stage. This, it was fet, had resuted in the spread of infection both within and between wards. The review aso pointed to the faiure of the infection contro team to cose wards to new admissions quicky enough, as opposed to pacing them under surveiance, a status that was, as became evident, poory understood by other staff. These factors had increased the infection rate. The report focused on the infection contro and outbreak management aspects of the incident. However, there was controversy at board eve, in part because views of the causes of the outbreak were subject to some considerabe variation. It is aso noteworthy that the report did not appear to have been widey circuated or the recommendations discussed with staff. Severa interviewees said that they had not had sight of the fina report and were thus not famiiar with the recommendations. Furthermore, athough there were some post-incident workshops run by the emergency panning team designed to earn essons from how the outbreak was handed, one ead nurse indicated that, because of the intense pressures experienced by ward staff, some found it hard to go back and reive their experiences of those weeks: Our emergency panning officer carried out some workshops where various peope across the organisation came together to discuss the good things, the bad things, what we needed to do differenty. The workshop I went to wasn't particuary we attended. I think by that time peope had... it was such... and I can't expain how stressfu a time it was, and peope were just kind of ike, Oh no, no, I can't revisit that. I don't think peope coud reay. I don't think because they didn't want to. I just don't think peope coud reive it. 216 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 The review aso identified the foowing issues: Faiure to cose wards at the start of the outbreak contributed to the spread of infection. Staff were not cear what under surveiance meant with regard to the movement of patients. Contractua arrangements for ward ceaning were not adequate to dea with the outbreak, not aowing for enhanced eves of ceaning or for termina ceaning before reopening a ward. There had been debate over whether or not to cohort infected patients in the same ward (and many wards had empty beds, being cosed to new patients). Cohorting aso aows empty wards to be ceaned and reopened for emergency admissions. However, the cohorting process invoves moving infected patients around the hospita, thus increasing the risk of further infection. It was decided during the outbreak, in agreement with commissioners, to cohort patients, aowing 10 wards to be ceaned and reopened. If one of the primary purposes of an acute hospita is to provide emergency heath care to the oca popuation, then anything which compromises that is of major significance. The decision to cose emergency admissions was made when there were many empty beds in the hospita, because affected patients were not cohorted. The review noted that, had cohorting taken pace earier, the emergency pathway woud not have been compromised. Infection contro was not heped by the od Victorian buidings and the hospita ayout. The Nightingae wards aso made the hospita vunerabe to the spread of infection. The ayout meant that it was not possibe to admit new patients to singe rooms, aowing them to be assessed for infection. In some cases, patients dispaying symptoms were moved to another ward to give them a singe room, thus increasing the risk of spreading the infection during transfer, and spreading infection to that other ward. Assessment for D&V symptoms in the emergency department was not routine, and patients infected in the community were bringing the infection with them when admitted to wards. Keeping potentiay affected patients in the admissions area aso meant that there was an ongoing source of infection which coud be transferred to other wards. At the time of the outbreak, rapid testing for the virus was not avaiabe on site. The deay in getting test resuts meant that patient management decisions were aso deayed. The recommendations The externa review made the foowing eight recommendations: 1. Wards shoud be cosed at an eary stage, rather than designated under surveiance, which ony prevents patients being moved out of a ward. 2. An area shoud be designated for suspected and confirmed cases that are admitted, to cohort them and to protect other patients. Bays shoud be provided for confirmed cases and singe rooms for suspected cases. 3. The infection contro team shoud assess risks and cinicay review cases, to inform isoation and ward cosure decisions. 4. The size and ski mix of the infection contro team shoud be reviewed given the size of the hospita and the age and nature of its faciities. 5. The provision of on-site testing faciities for the virus shoud be considered, to inform decisions about outbreak management at an earier stage. 6. Ceaning contracts shoud be revised to incude provisions for enhanced ceaning eves (e.g. frequent ceaning of touch surfaces) and termina ceaning in the case of outbreaks. 7. A process of inspection and sign-off shoud be introduced for ceaning cinica areas before they are reopened. 8. HPA guidance on hospita vira outbreaks of this nature needs to be updated. Queen's Printer and Controer of HMSO 2013. 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. 217

APPENDIX 4 Change foowing the incident There was a difference of opinion among those interviewed concerning what constituted the incident. One definition concerned the outbreak and spread of norovirus resuting in ward cosures. The incident generated significant management chaenges, with an incident command team being estabished in the boardroom and the infection contro team paying a centra roe. The outbreak aso resuted in negative reporting in the oca press, probaby causing ong-term damage to the trust's reputation. However, some staff, particuary senior managers, began to see this incident in the wider context of the trust's abiity to fufi its roe as a district hospita and to provide services to the oca popuation. As such, managing the outbreak, at east as it progressed, was positioned against the abiity to carry on deivering eective and emergency services. This was fet particuary strongy foowing the 96-hour cosure of the emergency pathway and prompted the decision to cohort infected patients to aow for wards to be reopened. A senior manager observed: The strategic objective was to reduce the chance of cross infection [but] became a situation where we had to switch the strategic objective to protect an emergency pathway. At a certain point, ninety-six hours into having the A&E shut to emergency admissions, the nature of the incident changed. Overa, there was a need to baance the consequences of controing the virus with maintaining emergency services. The same senior manager commented: So, our strategic objective then changed to maintaining the integrity of the emergency pathway, and the board had an open conversation about this, knowing that we might as a consequence of this, expose some patients to norovirus who otherwise woudn't have been. But the reative risk of norovirus, which is unpeasant, it's a forty-eight- to seventy-two-hour sef-imiting condition, whereas driving patients round in the back of ambuances, ooking for hospitas who can take them, is a much higher risk, and wi affect many more peope than potentia exposure to norovirus. Eective surgery was canceed for 5 weeks. However, the considerabe oss of income which this entaied (around 6M) was fet to be ess crucia to the trust, because canceing surgery had other significant non-financia consequences. For exampe, recovering from these canceations took much onger than recovery from the cosure of emergency services in reation to the rescheduing of operations. A shared notion of what constitutes an incident is ikey to have impications for how an organisation responds, and the types of changes that are panned to avoid further simiar incidents. A year after the outbreak, a number of changes were reported to have taken pace to avoid a further simiar situation. Nevertheess, it was acknowedged that norovirus woud remain in the community and that measures were required to prevent the infection spreading and imit the damage that an outbreak woud infict on the hospita's abiity to continue to provide services. Interviewees aso reported issues that had not changed, or changes that had not been sustained. The nature of the hospita estate was seen to be a major factor in the spread of the outbreak. This was not ony because of the predominance of Nightingae wards and the ack of singe and side rooms, which woud have enabed infected patients to be isoated, but aso because of the fabric of the buiding and the age and quaity of the furnishings. One senior manager remarked, If you wash a porous wa, it is sti porous. In addition, in some parts of the hospita, the doors were not wide enough to aow the type of bed used for edery patients to pass through, and isoation and cohorting thus became more probematic. There was widespread agreement that there was imited scope to dea with these probems. One senior manager commented that, In truth, the pace shoud be razed to the ground and something buit that's fit for the 21st, not the 19th century. 218 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 The ack of singe rooms meant that it was difficut to isoate patients who were dispaying symptoms of the virus before they were sent to a ward. Singe rooms woud aow time for patients to be isoated, to check if they were infected or whether or not their symptoms had other causes. Many fet that this was a main reason for the rapid spread of the virus in the hospita. Nightingae wards were seen as probematic because, if there was an infected patient on the ward, this exposed around 20 other patients to the virus. However, there were some differing views about the extent to which Nightingae wards reay were the probem. One ead nurse indicated that good hygiene practices coud minimise cross-infection irrespective of ayout. It was noted that, if patients were in four- or six-bed bays, with one nurse in each bay, then cross-infection was ikey to be restricted to the other three or five patients in that bay. Nightingae wards aso meant that, when restrictions were paced on patients moving out of wards where there had been an infection, a arger number of beds were affected rather than the sma number in a bay. If admissions were restricted because of infection, this coud resut in arge numbers of empty beds, unavaiabe for emergency admissions or eective surgery patients. At the time that the research was conducted, progress had been made in providing side rooms so that patients admitted through the emergency department dispaying symptoms of infection coud be isoated and their condition monitored. A ward refurbishment programme was aso in pace, which incuded reconfiguring the Nightingae wards into bays. However, these pans resuted in an overa oss of beds, as bays require more space. It was estimated that, foowing refurbishment, 85 beds woud have been ost across the hospita. Progress on the refurbishment was sow because, in an aready financiay chaenged trust, resources to fund this were imited. One board member indicated that they had put some money aside each year to fund this. In addition, there had been unforeseen probems, such as the discovery of asbestos, which had to be removed first and which deayed buiding work. At the same time, however, an increase in the number of side rooms and singe rooms woud aow the trust to make progress on achieving its targets for singe-sex wards. The report highighted ward ceaning as an area for attention with regard to the additiona ceaning required during a virus outbreak and procedures for ensuring that ceaning had been carried out to an acceptabe standard. Those interviewed said that good progress had been made and that they had estabished a new set of arrangements in coaboration with the ceaning company. The reporting of suspected cases to the infection contro team and the timing of the decision to cose wards were aso identified as contributing to the speed of the outbreak. Severa respondents said that they fet that wards were not cosed eary enough and that this had contributed to the spread of the virus. Foowing the outbreak, staff were encouraged to send specimens for testing eary on, so that suspected cases coud be confirmed and the appropriate steps taken as soon as possibe. This was reported to be generay improved, with staff being more vigiant. However, it was acknowedged that, for exampe, a patient who did not need assistance to go to the toiet coud have symptoms and not report them initiay, but that by the time they did report symptoms severa other patients might have gone to the toiet and been exposed to the virus on touch surfaces such as door handes or taps. Athough rapid reporting of suspected cases was seen to have improved, the infection contro team indicated that this was an area where staff needed constant reminders to remain vigiant, and that over-reporting was preferabe to under-reporting. The report aso noted that the infection contro team was sma for a trust of this size, and at the time of the outbreak one staff member was on ong-term sick eave. At the time of this study there had been no changes to the size or composition of the team, but there was no indication that this ack of resource had impacted on the spread of the outbreak. Additiona resources were brought in from neighbouring trusts when the outbreak escaated. The ack of in-house resources may have affected the executive's decision to ca in the HPA at an eary stage. Some comments were made by staff about the carity of the advice given by the infection contro team and how in some instances this conficted with the advice from the HPA. Interestingy, foowing the outbreak, hand hygiene attracted a ot of attention. Hand hygiene was not identified in the report as a contributory factor in the spread of the virus and the trust had a good record of Queen's Printer and Controer of HMSO 2013. 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. 219

APPENDIX 4 controing MRSA and C. difficie infections, indicating that hand hygiene had not historicay been a probem. However, at the time of the research, hand hygiene was mentioned as a contributory factor by many interviewees, who aso noted that ward ayouts meant that hand washing was not made easy for staff. In many Nightingae wards, for exampe, there might be two basins in the midde of the ward, requiring staff to wak up and down the ward frequenty to wash hands between patients. Acoho ge was provided by each bed, but this is not effective against norovirus. An operationa manager argued that there was a need to be more proactive, that portabe sinks shoud be paced at the entrance to wards, that ward staff shoud take responsibiity to ensure that they were repenished reguary and that hand-drying materias were avaiabe and disposed of safey. It was noted that the provision of washbasins was to be addressed in the refurbishment of wards. It was aso observed that there was some misunderstanding in this area among staff. For exampe, some thought that, if they wore goves, frequent hand washing was ess necessary. The infection contro team had run many training and awareness programmes about hand hygiene and dress codes since the outbreak, but there was a genera view that this remained a probem. Interviewees indicated that good progress had been made initiay foowing the outbreak, but that this was difficut to sustain. It was acknowedged that staff were busy and there was a need for constant reminders to be vigiant. Trust management had made it cear that they woud use discipinary procedures against members of staff not adhering to hand hygiene practices. The director of operations said: Fair enough, you know, there may be a situation where, for whatever reason, you've had a menta aberration and you're reminded to wash your hands and you do it. The second time, you get a etter saying, You sti haven't got this as a norma part of your daiy business. And on the third occasion you are then discipined. There were, however, no reports of any discipinary action being taken against members of staff, and some interviewees fet that senior management were not serious about this. One executive team member defended the ack of discipinary action, noting that it was recognised that staff worked under very difficut circumstances and that faiure to wash hands was not see as deiberate but as human error. Other senior managers indicated that a esson earned here was that you cannot drop your guard on hygiene and that there was a need for constant reinforcement. Athough improved hand hygiene is aways ikey to be beneficia in a hospita, it is interesting to observe that, 1 year on from the outbreak, this remained a major focus of attention and was deemed by many interviewees to have contributed to the spread of the virus. This is particuary interesting as it was not mentioned in the investigation report and the trust had a good record in controing other infections. This outbreak had a traumatic impact on staff, many of whom had never experienced anything as widespread as this. Ony senior managers were abe to contro the refurbishment of buidings and to increase the size of the infection contro team, so hand hygiene may have become the focus of activity as this was in the contro of a members of staff. Hand hygiene is aso an issue over which responsibiity is widespread doctors, nurses, ceaners and that crosses speciaties and eves in the organisation hierarchy. Moreover, a number of those interviewed, from different areas, fet that there was a bame cuture in the hospita, and that bame for the norovirus outbreak was attributed to ward staff, which had been demoraising. A number of genera essons were aso earned: it is necessary to imit the number of peope who move between wards during an outbreak, incuding non-cinica staff, such as the newspaper seer to prevent cross-contamination, domestic staff shoud work ony on either infected or non-infected wards agency nursing staff (the use of which was common) shoud not work shifts in both infected and non-infected wards. 220 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 One operationa manager indicated that, when it happened, the hospita did not pubicise the outbreak widey unti measures such as preventing visitors from coming to the hospita and cosing the emergency pathway had aready been taken. She indicated that the trust had become more confident and assertive in pubishing information about infections and communicating to visitors the need to be vigiant, especiay with regard to hand washing. This research was carried out approximatey 1 year after the outbreak, at which time the hospita had a sma number of cases of norovirus, having cosed five wards. It was fet that this was a good test of its abiity to manage the outbreak effectivey, and to protect emergency and eective pathways. Managing the outbreak The infection contro team beieved that the outbreak coud have been managed differenty, with ess impact on service deivery. Team members fet that, when the decision was made to bring in the HPA, measures were put into pace which resuted in a greater degree of ward cosure than was necessary. They aso fet that, once the outbreak had started to deveop, there was a degree of over-reporting (athough it was desirabe that staff notified the infection contro team of suspected cases) and that, for some patients, their symptoms had other causes. Their view was that the outbreak had been contained in about 2 weeks but that, as a resut of the invovement of externa bodies (commissioners and the HPA), it was proonged. Team members suggested that the HPA had been cautious and that the management of the outbreak was taken over by peope more experienced in managing infection contro in the community rather than in a hospita. It was argued that, had this approach not been taken, hospita services may not have been compromised. Severa interviewees observed that, when the outbreak team was set up in the boardroom, too many peope became invoved and noise eves were high, with ots of mini-meetings taking pace. Because the boardroom was ocated on the main hospita corridor, it was easy for peope to drop by and see how things were going. This was fet to have been unhepfu, and with this voume of traffic through the boardroom, some from infected wards, this coud have been a source of cross-contamination. It was aso fet that one of the probems that the outbreak team faced was deaing with conficting advice from different sources. In particuar, there were differences of opinion between the infection contro team and the HPA. The HPA was fet to be cautious in its approach and this inhibited the abiity to deiver services. However, it was acknowedged that the HPA had to be invoved, for the hospita's own protection, and as a resut the hospita was faced with comparing different forms of risk. By contrast, the commissioners were concerned with the poitica impications associated with the reduction in service provision and as a resut were keen to see actions that woud aow services to be resumed. Queen's Printer and Controer of HMSO 2013. 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. 221

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Appendix 5 Project outputs Buchanan DA. Heathcare managers: the other front ine? A 6-minute teevision interview, based on this project, avaiabe on the Cranfied Schoo of Management website and on the Cranfied section on YouTube from mid-juy 2010, accompanied by a PDF transcript. Aso pubished in the September 2010 issue of Think Cranfied, a quartery onine newsetter reporting on topica issues and Cranfied research. Buchanan DA. Two years from now, I don't just want to be doing what we do today more efficienty: CIP, QIPP, and strategic change in heathcare. Paper presented at the British Academy of Management Annua Conference, Symposium on Strategic Management and Performance in Changing Times, Sheffied, September 2010. Buchanan DA. NHS managers: the other front ine? Think Cranfied, September 2010. URL: www.som. cranfied.ac.uk/som/p15286/think-cranfied/2010/september-2010/nhs-managers-the-other-frontine (accessed 22 February 2012). Buchanan DA. Leading and impementing change: recognizing the other NHS front ine. Heath Service Journa Seventh Annua Leadership Forum, Cavendish Centre, London, 29 November 2010. Buchanan DA, Baiey C, Osbourne J. Up to our shouders in concrete: how the need for radica change inhibits radica change. Poster presentation to Deivering Better Heath Services, Heath Services Research Network and Service Deivery and Organisation Network Joint Annua Conference, Manchester, June 2010. Denyer D, Buchanan DA, Parry E, Osbourne JA. My job is wicked: the pressures and demands on midde management in the NHS. Deveopmenta paper, British Academy of Management Annua Conference, Aston University Birmingham, Heathcare Organization and Management track, September 2011. Moore C, Buchanan DA. Sweat the sma stuff: minor probems, rapid fixes, major gains. Paper presented to the 8th Internationa Conference on Organisationa Behaviour in Heathcare, Dubin, Apri 2012. Osbourne JA, Parry E. We re strugging with the sense of victim in the midde: the emotiona abour of management in heathcare. Deveopmenta paper, British Academy of Management Annua Conference, Aston University, Birmingham, Heathcare Organization and Management track, September 2011. Parry E, Buchanan DA. Reeasing time to manage. Manag Focus, Spring 2011, pp. 10 13. Pibeam CJ, Buchanan DA. A very unpeasant disease: the rapid reform and maintenance of infection. Paper presented to the Seventh Biennia Internationa Conference in Organisationa Behaviour in Heathcare, University of Birmingham, Apri 2010. Pibeam CJ, Buchanan DA. After the crisis: the maintenance mode of effective change. Heath Serv J Onine Resource Centre, 16 August 2010. URL (avaiabe to HSJ subscribers): www.hsj.co.uk/resource-centre/yourideas-and-suggestions/changes-in-patient-safety/5017551.artice (accessed 22 February 2012). Pibeam C, Moore C. Are you takin to me?: a socia network anaysis of a change agent s interactions. Deveopmenta paper, British Academy of Management Annua Conference, Aston University, Birmingham, Heathcare Organization and Management track, September 2011. Pibeam CJ, Buchanan DA. A very unpeasant disease: successfu post-crisis management in a hospita setting. In Dickinson H, Mannion R, editors. The reform of heath care: shaping, adapting and resisting poicy deveopments. Houndmis, Basingstoke: Pagrave Macmian; 2011 pp. 211 26. Queen's Printer and Controer of HMSO 2013. 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. 223

APPENDIX 5 Research briefings We aso pubished a series of short (four-page) research briefings. These each addressed a singe topic or theme and they were written for our end-user management audience. They were avaiabe in hard copy (coour printed A4 card) and aso as PDF web downoads. Buchanan DA. Reeasing time to manage: what stops midde and front ine managers from doing their jobs more effectivey, and what can you do about it? Cranfied Heathcare Management Group Research Briefing 1, September 2010. Buchanan DA. Names, ranks, and numbers: how many managers does the NHS have, and is that enough? Cranfied Heathcare Management Group Research Briefing 4, October 2010. Buchanan DA. Spot the manager: how to identify midde and front ine managers in the NHS. Cranfied Heathcare Management Group Research Briefing 5, November 2010. Buchanan DA. Are heathcare management jobs becoming extreme jobs: and what are the impications of this trend? Cranfied Heathcare Management Group Research Briefing 7, February 2011. Buchanan DA. Esenham crossing: a whoy avoidabe accident. Cranfied Heathcare Management Group Research Briefing 9, May 2011. Buchanan DA. Reinforcing the management contribution. Cranfied Heathcare Management Group Research Briefing 10, May 2011. Buchanan DA, Moore C. Management capacity: framework and assessment guideines. Cranfied Heathcare Management Group Research Briefing 14, October 2011. Buchanan DA. Grandmother s footsteps: the institutiona context of management work. Cranfied Heathcare Management Group Research Briefing 18, February 2012. Gascoigne C. A review of research on extreme jobs: ong hours, intense effort, high chaenge. Cranfied Heathcare Management Group Research Briefing 19, May 2012. Moore C. Knowing me, knowing you: interpersona reationships between managers and hospita consutants. Cranfied Heathcare Management Group Research Briefing 11, May 2011. Moore C. You are what you emai: how do you manage your reationship with your inbox. Cranfied Heathcare Management Group Research Briefing 12, May 2011. Moore C. Sticking pasters over big probems: are you managing your wicked probems or using sticking pasters? Cranfied Heathcare Management Group Research Briefing 13, September 2011. Moore C. Menta toughness: appying sports and navy principes to heathcare. Cranfied Heathcare Management Group Research Briefing 16, December 2011. Moore C. Sweat the sma stuff: minor probems, rapid fixes, major gains. Cranfied Heathcare Management Group Research Briefing 17, January 2012. Osbourne J. What motivates NHS managers?: is it just money? Cranfied Heathcare Management Group Research Briefing 3, December 2010. 224 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Osbourne J. Chaenges facing heathcare managers: what past research reveas. Cranfied Heathcare Management Group Research Briefing 6, January 2011. Osbourne J. Managers have feeings too: emotions of heathcare managers. Cranfied Heathcare Management Group Research Briefing 8, Apri 2011. Pibeam CJ, Buchanan DA. After the crisis: the maintenance mode of effective change. Cranfied Heathcare Management Group Research Briefing 2, September 2010. Turnbu James K. What eadership practices are needed in compex heathcare organizations? Cranfied Heathcare Management Group Research Briefing 15, November 2011. Queen's Printer and Controer of HMSO 2013. 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. 225

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Appendix 6 Reated pubications This appendix ists pubications that, athough not drawing directy from the fiedwork of this project, are authored or co-authored by members of the project team and address issues cosey reated to the aims of the project. These pubications thus form part of the overa dissemination of findings arising from and reated to the project. Adams R, Tranfied D, Denyer D. A taxonomy of innovation: configurations of attributes in heathcare innovations. Int J Innov Manag 2011;15:359 92. Adams R, Tranfied DR, Denyer D. Process antecedents of chaenging, under-cover and readiy-adopted innovations. J Heath Organ Manag 2013;in press. Briner RB, Denyer D, Rousseau DR. Evidence-based management: concept cean-up time? Acad Manag Perspect 2009;23:19 32. Buchanan DA. Good practice, not rocket science: understanding faiures to change after extreme events. J Change Manag 2011;11:273 88. Buchanan DA, Storey J. Don t stop the cock: manipuating hospita waiting ists. J Heath Organ Manag 2010;24:343 60. Buchanan DA, Fitzgerad L. New ock, new stock, new barre, same gun: the accessorized bureaucracy of heathcare. In Cegg S, Harris M, Höpf H, editors. Managing modernity: beyond bureaucracy? Oxford: Oxford University Press; 2011. pp. 56 80. Fitzsimons D, Turnbu James K, Denyer D. Aternative approaches for studying shared and distributed eadership. Int J Manag Rev 2011;13:313 28. Turnbu-James K. Leadership in context: essons from new eadership theory and current eadership deveopment practice. Paper commissioned by The King s Fund to inform the Commission on Leadership and Management. London: The King s Fund; 2011. Submitted and under review Buchanan DA, Denyer D. Researching tomorrow's crisis: methodoogica innovations and wider impications [pubished onine ahead of print 13 November 2012]. Int J Manag Rev 2012. doi:10.1111/ijmr.12002. (Submitted on invitation from guest editors for specia issue on management research methods and practice.) Queen's Printer and Controer of HMSO 2013. 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. 227

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Appendix 7 Sweating the sma stuff: minor probems, rapid fixes, major gains Paper presented to the Eighth Internationa Organizationa Behaviour in Heathcare Conference, Trinity Coege Dubin, Ireand, 15 18 Apri 2012 Cíara Moore, SDO Management Feow, and David A. Buchanan, Professor of Organizationa Behaviour, Cranfied University Schoo of Management Corresponding author: David A. Buchanan Professor of Organizationa Behaviour Cranfied University Schoo of Management Cranfied, Bedfordshire, MK43 0AL, UK T: + 44 (0) 1234 751122 x 3481 F: + 44 (0) 1234 751806 E: David.Buchanan@Cranfied.ac.uk M: + 44 (0) 7850 143 602 Abstract Soving sma, annoying probems may appear to be unimportant in a poitica and economic cimate that focuses attention on radica ong-term changes to the organization, deivery, funding, and reguation of the heathcare system. However, as the initiative reported here suggests, sma changes can generate major benefits for patients, staff, and hospita performance. This approach can aso strengthen cinica manageria reationships, which are key to arger scae initiatives, and which can suffer when the sma stuff is not fixed. The success of this initiative is expained with reference to a process mode of change combining context, content, process, and individua dispositions. This mode coud aso identify other settings where this approach is ikey to be effective. On the basis of this experience, heathcare managers may be advised to be aert to what appear to be minor unresoved issues, and to address these in addition to undertaking arger scae, onger term projects. Acknowedgements: The research on which this paper is based was funded by the Nationa Institute for Heath Research Service Deivery and Organisation programme (award number SDO/08/1808/238, How do they manage?: a study of the reaities of midde and front ine management work in heathcare ). Discaimer: This paper is based on independent research commissioned by the Nationa Institute for Heath Research. The views expressed in this presentation are those of the authors, and not necessariy those of the NHS, the Nationa Institute for Heath Research or the Department of Heath. Queen's Printer and Controer of HMSO 2013. 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. 229

APPENDIX 7 For want of a nai... For many midde managers, they can see the probem and know how to fix it, but it's easy to et it drop. Wi I pick up the coding batte today? Maybe not. Operations manager, Cearview hospita Very sow, very frustrating, and quite often not enough progress in an acceptabe time, and the base probem remains. And after some time it becomes embedded and accepted because the midde manager concudes it's too hard to address. Interim director, North Somerton hospita The aim of this paper is to expore the potentia benefits to patients, staff, and overa organizationa performance, of addressing minor probems in an acute hospita setting unanswered e-mais, deayed equipment orders. These issues can be overooked in a context where major change is at a premium. However, a sma-scae initiative designed to address such issues reveas the potentia to generate savings, increase staff morae, improve quaity of patient care, expose underying probems, and strengthen cinica manageria reationships. The success of this initiative set the foundation for further improvements, in this and other services. The change continuum from fine tuning to transformationa impies the reative superiority of the atter (Stace and Dunphy, 2001; Kotter, 2008), which may be miseading. In the current economic cimate, attention focuses on radica changes to the ways in which heathcare is funded, organized, deivered and reguated (Department of Heath, 2010). For the Nationa Heath Service (NHS) in Engand, meeting the Nichoson chaenge to cut the annua budget by 20 biion by 2014 15 invoves impementing major cost improvement programmes (CIPs), which have meant cutting tens of miions of pounds from hospita budgets. Nationa poicy means that these reductions in spend must be accompanied by pans to maintain Quaity, encourage Innovation, increase Productivity, and strengthen Prevention (of incidents which jeopardize patient safety); the so-caed QIPP agenda. This impies disruptive innovation (Christensen et a., 2000), not tinkering (Abrahamson, 2004). These poicy-driven changes accompany the chaenges facing a modern heathcare systems: rising patient expectations; ageing society; wider information avaiabiity; changing nature of disease; advances in treatments; changing workforce (Department of Heath, 2009). The traditiona mode of the acute hospita is thus now in question, with the advent of poycinics, care in the community, improved management of ong-term conditions, and the integration of services in further attempts to reduce costs and streamine care (Edwards, 2010a). Aims and methods This initiative was part of a wider study of management contributions to change to improve cinica and organizationa outcomes. Cinica/medica manageria reationships are a component of the receptive context for change (Pettigrew et a., 1992), and evidence shows that initiatives that are cinicay ed are more ikey to succeed (Locock, 2001). In addition, change in a arge, compex, pubic sector, professiona bureaucracy is (aegedy) intrinsicay probematic (Øvretveit and Asaksen, 1999; Edwards, 2010b). But the NHS is expected to undergo radica change (Department of Heath, 2009): the productivity chaenge, the scae of the chaenge before us (p. 3), change on an unprecedented scae (p. 7). This agenda does not impy fine-tuning. How are cinica/medica manageria reationships deveoping in this context? Are sma changes of itte or no vaue in the face of this unprecedented chaenge? At Cearview hospita (pseudonym), to expore medica manageria reationships, piot interviews were conducted with seven consutants senior doctors who were eading speciaists with internationa reputations in their respective fieds of medicine. Contrary to expectations, and to traditiona stereotypes (McCarthy et a., 1993), these doctors recognized and wecomed the vaue of management support (Moore, 2011). However, they aso noted that management workoad pressures meant that sma probems were often not resoved. For exampe, one consutant had waited eight months for a connection to aow a 230 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 coeague to share the printer in his office. A source of daiy frustration, such probems contributed to a perceived ack of management action, and damaged manageria credibiity. The aims of this initiative, therefore, were to identify the sma probems in one cinica service, to understand why these had not been tacked, to fix these quicky, to estabish the benefits, and to assess the appicabiity of this initiative to other cinica services. The Cearview context When the computer on the ward was bust, I said to the ward manager, we need a new one, and she said we need to ask the operations manager. When I asked the operations manager, she said the ward manager coud do it. So it takes ages to just sort out the computer. It's this inefficiency which is irksome. Consutant, medicine division, Cearview hospita Cearview is an acute hospita with an annua budget of around 600 miion, 7,000 staff, and 1,000 beds. Cearview was impementing cost improvement projects (CIPs) to reduce a projected 10 miion deficit in 2011/12, and it was predicted that further savings of over 18 miion woud be required to reach break even, given the rising costs of pay and medica suppies. Cearview had seven divisions: cancer; women and chidren's and; emergency and perioperative care; diagnostics; medicine; neurosciences; surgery. The medicine division had CIPs totaing 9 miion at the time of this initiative. The initiative reported in this paper invoved the gastroenteroogy service, which was part of the medicine division, with an annua budget of around 4.5 miion, 70 staff, 6 consutants, a 22 singe-rooms ward, a five-room endoscopy suite, and daiy outpatient cinics. This was a high voume service with a team that was receptive to change, and this initiative had the support of one of the consutants who encouraged his coeagues to participate. Sweat the sma stuff Normay, if I need a computer, I phone the shop, or get onine, and say printer and it arrives the next day. Here you have to fi in severa forms. They go to someone who e-mais back to say you've fied in the wrong forms. You send it back again, they take severa weeks, and then they procure what seems ike the most expensive computer in Christendom. And eight weeks ater, if you are ucky, something that ooks ike a computer arrives, but isn't the one you ordered. Consutant, medicine division, Cearview hospita This initiative, caed Sweat the sma stuff, was impemented by a three-person team, who first agreed a project charter, which was then approved by the medicine division's budget hoder and associate director. The team impemented a five-day process; coud minor probems be identified, expored, and resoved in such a short time? Why had those sma issues not been resoved previousy? And what impact woud soving these issues have on the staff concerned and patient care? The three team members' roes were: The animateur In the arts word, the animateur is a driving force, a faciitator, a promoter who inspires others and gets them engaged in a project. This management roe has aso recenty been recognized as key in heathcare commissioning settings (Checkand et a., 2011, forthcoming). For this initiative, the animateur was the division operations manager, who designed and coordinated the project, invited the head of the gastroenteroogy service to tria this approach with his staff, and recruited the other two members of the project team. Queen's Printer and Controer of HMSO 2013. 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. 231

APPENDIX 7 The consutant champion It was important for the team's membership to incude one of the consutants who had expressed frustration with management's perceived inabiity to fix sma probems. His membership signaed that this was a medica manageria coaboration which he was championing. The consutant sent the project's trigger e-mai to his team, incuding doctors, nurses, management and administrative staff, inviting them to identify appropriate issues. The who knows who knows what roe This team member, persona assistant to the assistant operations director and operations managers, had worked at Cearview for severa years in an administrative capacity, had deveoped an extensive network, had a sma team with its own networks, and understood the short cuts through which issues coud be resoved quicky. Katz and Lazer (2003, p. 20) describe this as the who knows who knows what team roe. Her detaied tacit operationa knowedge of the hospita was thus a key ingredient of the success of this initiative. The first task that she and her team undertook invoved isting their contacts in support areas peope who they knew and trusted, and who coud be caed upon to hep resove issues quicky. Customer service One of the themes emerging from the piot interviews concerned customer service. Hospita staff who pace orders or requests through interna systems expect a response simiar to that which they receive when shopping onine at home. Amazon and Tesco, for exampe, process orders rapidy, and e-mai customers to advise of deays, offering discounts when things go bady wrong. But hospita staff note that, when they order equipment, or request that issues be resoved, they often do not know whether or not their request has been received, if it is receiving attention, or what stage their request has reached. This initiative, therefore, sought to ensure that the responses from the project team were rapid, and that staff were kept up to date with regard to progress on the issues they raised. Those staff members were thus seen as cients, and the aim was to treat them as such, by giving them one, three and five day updates. Day 1: 24 hours A cients were contacted within 24 hours of registering their issue with the project team. They each received an e-mai thanking them for registering their issue, and they were advised that a further update woud foow on day three. In most cases, a brief conversation ensured that background information was captured concerning the nature or frequency of the issue raised, and its impact. This information aowed assessment of how successfuy the issue had been resoved, in terms of time, money and other benefits. Day 3: update On the third working day of the initiative, a cients were updated on progress with their issue. Of five issues, one had been resoved at this point, and the others a had actions in progress. Cients were deighted that their issues were resoved or were cose to resoution. Day 5: cosure The fina step; workabe soutions had been identified for a issues, three had been competed, and two required some further work (expained beow). Those who had contributed issues to the initiative were thanked and invited to provide feedback on the process. A form was designed with which to register issues, but most came through informa requests to the project champion. It was expected that we need more staff woud be a common theme, but this was not so. The cients who raised the issues for fixing are shown in Tabe 1, and were a mix of administrative, nursing, manageria and medica staff. Probems and fixes Five sma probems were raised, invoving patient pathways, two separate issues reated to coding, a scanner, and patient safety. What were these probems, why had they not previousy been resoved, how were they fixed, and what were the outcomes? 232 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 1 Sweat the sma stuff cient base Issue The patient pathways fix The coding fix (1) The coding fix (2) The scanner fix The patient safety fix Raised by Deputy operations manager Speciaist nurse and consutant gastroenteroogist Speciaist nurse Medica secretary Consutant gastroenteroogist The patient pathways fix For one gastroenteroogy manager, the issue concerned the ack of knowedge among administrative and cerica staff in the hospita appointments centre, and in the cinic and endoscopy suite, concerning patient pathways. This ed to overbooked and underbooked cinics, to patients being booked outside waiting times targets (18 weeks, or 2 weeks for cancer patients), to booking with the wrong cinician, or booking onto the wrong endoscopy ist. She fet that this probem reated not just to understanding targets, but more importanty concerned understanding the needs of the speciaty and its patients. The gastroenteroogy management team had requested that a ink be estabished between the cinic and the service a member of the cinic team who woud act as expert on gastroenteroogy patients. Staff numbers, and the movements of staff between cinic areas, prevented this. This probem had a significant impact on how efficienty the cinics woud run. If a patient was paced in the wrong cinic, consutant time woud be wasted, and the patient woud have to be aocated to the correct consutant, invoving a further hospita visit. This was occurring in every cinic, wasting up to haf an hour each time. The costs are shown in Tabe 2. Overbooked cinics often ran ate, and incorrect patient bookings added to the frustration. Fixing this issue woud thus reease time which consutants coud spendwithpatients. A discussion with the deputy operations manager reveaed that many administrative staff did not understand the patient pathways. As these pathways had not been mapped, the operationa ead for this initiative and the deputy operations manager decided to create a visua map (on one page) of patients' pathways based on a condition of the week tempate; for exampe, coeiac disease, the patient journey, correct pacement, symptoms and causes, and ead consutants for the speciaist area. These maps were the presented at one of the daiy faciitated meetings, for cinic, endoscopy suite and administrative staff, with the aim of accumuating a manua of pictoria representations of a the main pathways. The coding fix (1) Key point is the code for immunosuppression monitoring in cinic we have been waiting for MONTHS/ YEARS for this. I have no idea why, but it drives us a nuts. (consutant gastroenteroogist, Cearview hospita: capitas in origina e-mai) TABLE 2 The impications of patient pathway errors Number of cinics Time ost Vaue 20 a week 30 minutes per cinic 56 consutant's time Annua savings if fixed: 420 hours (42 working weeks) 47,040 Queen's Printer and Controer of HMSO 2013. 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. 233

APPENDIX 7 Coding is the process of recording the treatments that patients receive; the accuracy of the coding thus affects the payments that the hospita receives from its heathcare commissioners. There were two issues reated to coding. The first concerned immunosuppression monitoring, for which a code was required to enabe the cinic to be set up and registered on the hospita information system, and then to aow data to be coected on this nurse-ed service. This probem took ten minutes to fix. The norma process for setting up codes is to create a change in methodoogy recording form (CMR). The information on this form was used by the information services team to aocate a code. When first asked why this code had not been set up, the directorate support manager said that they were waiting for the information services team to respond. Ten minutes ater, the manager reaized that the code had aready been aocated, about a month earier, and was sitting in her inbox. Why had this not been actioned? The manager had been overwhemed with work. She had taken on an additiona roe of booking patients into speciaist procedures, and was jugging this with managing a team, with mutipe pathways and targets. It was aso ascertained that her inbox was fu; she may have seen the message and acknowedged it, but with managing her extended workoad, she had not actioned this. Within a day of the initiative she agreed to meet with the speciaist nurse who woud run the cinic, and together they finaized the cinic times and numbers and the cinic was set up. From the moment this cinic is set up the team wi be abe to count their activity more accuratey and generate income (see Tabe 3). The coding fix (2) The second coding issue was more compex. The gastroenteroogy team had been asked to tria a new teephone cinic for patients with chronic infammatory bowe disease. The aim was to estabish an open access advice ine for patients, but a code was required to capture the activity of this service. This woud ensure safe medication for those using highy toxic and expensive drugs; promote sef-management of the condition by providing expert advice; avoid unnecessary admissions; and faciitate eary discharge. The advice ine woud be funded by reducing the need for a nurse foow-up. The team had pioted this as a ghost service expecting commissioners eventuay to fund it. However, the ack of a teephone cinic code meant that nurses were manuay coecting the data, and forwarding this information to the finance department to cost on a monthy basis, thus reducing the benefits from reduced nurse input, and adding administrative time of two hours a month compiing that information. The deputy operations manager had set up this teephone cinic, and was advised by the assistant director of commissioning not to set up a code, as this was not required for this ghost service, for which payment from commissioners may not be forthcoming. However, she was given different advice by the information services manager who she shoud have approached first. This iustrates the probems of understanding the roes and responsibiities of others in a compex organization, where probems may not be resoved through ack of such basic information. A CMR form was competed and the service was set up on the hospita information system, reducing the need to capture data manuay. The main benefits for patients incuded admission avoidance, and reduced number of hospita visits. TABLE 3 Coding fix (1) Number of patients Income 5 per week 95 per patient Annua tota redeemed Based on a 42 week year 19,995 234 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 The scanner fix A team of three medica secretaries suggested that a barcode scanner woud reduce the time spent tracking the ocation of patients' medica records (which are bar-coded for identification purposes), and manuay ogging this information on the hospita information system. The team had used a scanner severa years ago, but it was not repaced when it broke down. One option was to use a spare scanner from another department, but that turned out to be incompatibe with their computers. When asked why a new scanner had not been acquired, the team responded that they had assumed at the time it was due to funding issues. It normay took 30 minutes a day to manuay enter patient records, and this time coud be haved with a scanner. An appropriate scanner cost 89, and was bought within three working days. This was made possibe in part due to the preparatory work for this initiative, as the budget hoder had been aerted to the possibiity of such costs arising. She had agreed that, as ong as the expenditure was justified, she woud support such purchases. In addition, the who knows who knows what member of the team knew that it was possibe to procure urgent goods for next day deivery by using a hospita credit card. Standard processes can take weeks to unfod. The scanner arrived on Day 5, but had to be processed by goods inwards, the hospita's centra deivery point where orders are checked before interna deivery. The medica secretaries got their scanner on Day 6. One responded, Fantastic; we are enjoying having one ess task for sure. Such a sma, inexpensive item has saved us time and is making a boring job much ess of a chore. The origina scanner had not been repaced for over five years (see Tabe 4). The accumuated cost of 95 ost working days over those five years was estimated to be 11,340. The patient safety fix One of the great frustrations in hospita medicine is deaing with enquiries or the resuts of investigations for patients under someone ese's care. With a triage system, patients woud often be admitted on the day I was on ca for genera medicine, but woud be triaged to another speciaty, so I woud never see them. The way patients were aocated in the morning meant that they were not correcty re-aocated to the new consutant on the hospita patient administration system. As a consequence, the resuts of every investigation performed during the admission, and questions from GP surgeries, woud continue to come to me, generating significant amounts of wasted time for me and my secretary. The same woud appy in reverse for many of my patients. This was rectified simpy by educating those responsibe for patient aocation, and wi save enormous amounts of time across the division over the course of the year. Consutant gastroenteroogist, Cearview hospita One gastroenteroogy consutant had observed that, foowing his on-ca days, he often found that patients who had been admitted were sti registered in his name on the hospita system. He was thus spending around two hours each month deaing with the administration reated to patients who were no onger under his care, and this incorrect aocation coud pose patient safety issues. This issue affected the team of TABLE 4 The scanner fix Time ost with Tota annua manua input Annua time ost hours ost Working days ost 90 minutes ost per day 18,900 minutes, based on 42 weeks 315 39 Tota annua Time saved with scanner Annua time saved hours saved Working days saved 45 minutes a day 9450 minutes saved, based on 42 weeks 157 19 Queen's Printer and Controer of HMSO 2013. 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. 235

APPENDIX 7 six consutants and perhaps the medicine division as a whoe. This was an important issue, so it was important to resove it. The hospita information system was imited in terms of visua presentation and reporting. Some years ago, a separate web-based system was deveoped, patient monitor, which captured patient detais and aowed consuting teams to coate these by medica firm and make patient notes or action ists. This aso aowed them to print out patient ists with notes which made handovers easier. The main hospita system did not have this function, but patient monitor coud ensure that patient changes were recorded in the main system. At the medicine division daiy morning report, a patients admitted the previous day were discussed and, if necessary, aocated to the correct speciaity. For exampe, a patient admitted by the on ca gastroenteroogist may have a cardioogy probem, and so woud be aocated to the cardioogy team at morning report. The administrative team who attended this meeting had to enter the required changes, to cinica team and consutant, ive onto patient monitor. However, at this stage of the process, the administrative team occasionay overooked the change of consutant. The patient fow manager agreed to ensure that his administrative team were aware of the need to compete these aocations fuy and correcty. Patients coud aso be moved to the care of a different consutant some time after admission, and the ward cerks had to be aware of this probem, too. The deputy operations manager agreed to put this item onto the agenda of the ward cerks' forum. Whie the soution to this probem was cear, given the education requirement, it woud take time for these changes to become sustainabe, requiring ongoing monitoring, audit, and training. The consutants were peased with this change. Athough this woud reduce the time they spent on unnecessary administration, the main benefit here concerned patient safety. A subsequent audit showed that a patients were being aocated correcty (Tabe 5). Much doing to be done If NHS managers are strugging it is because of the size of the agenda and the ack of respect for the management task invoved; and the systematic ack of investment in earning it is hard to earn together when there is so much doing to be done. Maby, 2011, p. 19 Tabe 6 summarizes the five probems, the nature of each issue, why it had not been resoved, how it was resoved, the cost of the fix, and the benefits which fa into five categories: financia: income generation processua: safer patient aocation tempora: tasks performed more quicky; ess waiting time emotiona: reduced annoyance, boredom, frustration reationa: improved inter-professiona reationships The benefits to patients concern safety, reduced hospita visits and waiting times, and cinica staff who have more time to spend with them. The benefits to staff reate to reductions in routine manua work, and TABLE 5 The patient safety fix Number of hours Vaue 2 hours per on ca duty 224 for 2 hours 6 consutants, 8 on ca sessions per annum Tota annua savings 96 hours 10,752 236 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 TABLE 6 The sma stuff sweated: summary Probem Why was this not fixed? The fix Cost of fix Benefits of fix Patient pathways Mutipe, compex pathways not cear to staff booking patients into wrong cinics Obvious soution a dedicated iaison person not possibe due to staff shortage and budget restrictions A manua of visua process maps to expain pathways to endoscopy cinic and administrative staff; buit up graduay and presented at weeky meetings None Less consutant time wasted, patients spared further hospita visit, 47,000 consutants' time Coding (1) Cinic code not organized, unabe to caim income Code was set up, but directorate support manager overooked e-mai due to pressure of work Code registered; short conversation with speciaist nurse who woud run the cinic to agree cinic times and patient numbers None 20,000 new annua revenue Coding (2) Teephone advice ine code not set; manua data entry Senior commissioning management advice that a code was not required Information services manager gives different advice, code is set up None Less administration for speciaist nurses, reduced admissions and fewer hospita cinic visits for patients, improved service demand management Scanner Broken, not repaced for five years Spare barcode scanner in another department did not work; assumed no budget for repacement New scanner costed and acquired in five days (pus one day's deay in the goods inward department) 89.00 157 FTE secretaria hours saved pa, ost time over five years cost 11,000, 2,500 secretaria time saved pa Patient safety Incorrect patient aocation to medica teams Mechanism in pace, but not used consistenty due to poor understanding Issue brought daiy to medicine division morning report, where patients are reaocated to correct cinica team foowing on ca admission None Reduced time spent on administration, audit shows patient safety improved, 11,000 consutants' time saved consideraby ess frustration. Corporate benefits incude income generation, improvements in quaity of care and safety, and improved reationships, thus contributing to the impementation of more radica initiatives in future. The sma issues underpinning this initiative had not previousy been addressed due to: 1. workoad 2. budget and ogistica probems 3. incorrect advice 4. ack of understanding. It is interesting that, in ony one case, the faiure to have fixed the issue was due to ack of finance (for an additiona staff member), and that was resoved with the creative and cost-neutra deveopment of visua process maps. Ony one fix invoved minor expenditure. Informa feedback from the gastroenteroogy team was positive. The opportunity to be invoved in soving those issues was wecomed, athough two gastroenteroogy managers (deputy operations and directorate support), the animateur, and the who knows who knows what, did most of the work. However, Queen's Printer and Controer of HMSO 2013. 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. 237

APPENDIX 7 the work invoved was hardy burdensome: the animateur kept a og and cacuated that, in heping to resove those issues, she had spent 40 minutes in conversations over five days. Athough it is managers who often eave those sma issues unresoved, they typicay have a better understanding of how to fix them. Cinica and medica staff often ack, and may have itte time or desire to deveop, the networks and the organisationa knowedge that contributed to this initiative. Administrative staff were aso a vauabe source of potentiay untapped knowedge, particuary with regard to negotiating the bureaucracy and finding short cuts. Drawing on findings from the wider project, midde managers in acute hospitas are confronted with ong and compex change agendas, with many conficting priorities, a of which are aways urgent. This has been described as mutioading (Bruch and Menges, 2010; Maby, 2011), and was a feature of management work at Cearview. In this context, it is perhaps not surprising that big change attracted attention, and sma stuff was overooked. And as is often the case in heathcare, the soutions to these sma probems saved expensive staff time, but were not cash reeasing, but one woud generate income. From a theoretica standpoint, how can the success of this initiative be expained? Drawing on an infuentia processua perspective (Pettigrew et a., 2001; Dawson, 2003), Waker et a. (2007) argue that change outcomes are shaped by the integrative infuence of context, content, process, and individua dispositions. Context refers to forces in the externa and interna environments. Content concerns the changes being impemented, whether they are fundamenta or incrementa, changing the organization's character or fine tuning, episodic or continuous. Process reates to the actions of change agents. Significant individua factors incude dispositions, behaviours, and reactions to change. Tabe 7 summarizes the nature of these four sets of factors in this case. First, there were many externa and interna pressures for change. Second, the change agenda was driven by the staff of the cinica service, and was not externay imposed. In addition, the changes were not radica, but invoved fine-tuning that was perceived to be important. Third, the three-person team animateur, consutant champion, who knows who knows what appears to have been particuary effective, in aunching the initiative, and in bringing it rapidy to a successfu concusion. Finay, the frustrations, and the ambitions of those invoved were key to creating and sustaining interest in and commitment to the project. From a manageria standpoint, it woud appear to be a simpe matter to extend this sma-scae initiative to another cinica service. However, it aso seems reasonabe to assume that the probabiity of success TABLE 7 Factors affecting change success Factor Context: factors in externa and interna environment Sweat the sma stuff Externa: demands for productivity, efficiency, cost savings, improved care quaity and safety Interna: high voume service, high performance team, ambitious to improve, sma, known, but frustrating unsoved probems Content: the changes being impemented Sma probems, incrementa change, fine tuning, tinkering, episodic, not ongoing fundamenta, radica or strategic change Sourced from mix of team members cients their issues, their priorities, not externay imposed Process: actions taken by the change agents Estabished project team with three members: animateur, cinica champion, and who knows who knows what member Initia groundwork with powerbrokers; rapid process with five-day deadine, constant feedback to cients Individua dispositions: attitudes, behaviours, reactions to change High performance, high aspiration team receptive to change; enthusiastic medica support; ambitious project ead Frustration with bureaucracy, inefficiencies, and sow pace of change, especiay with apparenty minor issues 238 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 esewhere may depend on the extent to which the configuration of context, content, process, and individua dispositions broady mirror those encountered in the, perhaps idea, setting of this particuar gastroenteroogy service. Where conditions may not appear to be idea, this mode can aso act as a guide to remedia action. Finay, considering the processua, tempora, emotiona and reationa benefits, what is the significance of an initiative focusing on minor issues in a cimate of unprecedented chaenge? Was this of vaue, or was this a diversion from the main transformationa agenda? This initiative can be considered to have vaue in at east three respects. First, severa issues were resoved quicky, to the satisfaction of staff invoved, at itte cost other than sma amounts of time and a 90 scanner. For those faced with the daiy frustrations of those minor annoyances, those quick and permanent fixes were wecome. One of the consutants invoved subsequenty used the quick fix deveoped in one of these instances to resove another, simiar probem just as rapidy. And it was panned to extend this initiative to other divisions and services. Second, tinkering has a recognized pace in the tookit of change management. Abrahamson (2000; 2004) describes tinkering as fidding with the nuts and bots, of what aready exists in order to generate inspired soutions to current probems, rather than trying to create something new from scratch. He argues that tinkering is typicay inexpensive and rapid, is not as destabiizing as arge-scae radica change can often be, and is more ikey to succeed (or to have ower opportunity costs of faiure). Third, previous research has suggested that one predictor of the success of the next change initiative concerns an organisation's past experience (Waker et a., 2007). A track record of successfu change encourages a predisposition to support further initiatives. Commentary in this fied thus recommends achieving quick wins (for a heathcare exampe, see Kaber et a., 2011). Sweat the sma stuff achieved severa wecome and visibe quick wins, with possibe medium and ong term benefits beyond the five day programme. As previousy indicated, another heathcare-specific predictor of the success of change ies with the quaity of cinica/manageria reationships. This initiative served to strengthen reationships which were positive at the start, abeit weakened by those ongoing unresoved probems. In other words, the custer of soft benefits that emerged from this sma-scae initiative may contribute in significant ways to the support for, and the impementation and success of, the more radica, transformationa, disruptive change agenda facing heathcare. This initiative aso heped to cement the mutua interprofessiona trust, respect, and coaboration on which those arger-scae chaenges are ikey to depend. References Abrahamson, E. (2000) Change without pain, Harvard Business Review, 78(4): 75 9. Abrahamson, E. (2004) Change Without Pain: How Managers Can Overcome Initiative Overoad, Organizationa Chaos, and Empoyee Burnout. Boston, MA: Harvard Business Schoo Press. Bruch, H. and Menges, J.I. (2010) The acceeration trap, Harvard Business Review, 88(4): 80 86. Checkand, K., Snow, S., McDermott, I., Harrison, S. and Coeman, A. (2011) Animateurs and animation: what makes a good commissioning manager?, Journa of Heath Services Research & Poicy (forthcoming). Christensen, C.M., Bohmer, R. and Kenagy, J. (2000) Wi disruptive innovations cure heath care?, Harvard Business Review, 78(5): 102 12. Dawson, P. (2003) Reshaping Change: A Processua Approach. London: Routedge. Queen's Printer and Controer of HMSO 2013. 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. 239

APPENDIX 7 Department of Heath (2009) NHS 2010 2015: From Good to Great. London: The Stationery Office. Department of Heath (2010) Equity and Exceence: Liberating the NHS. London: Her Majesty's Stationery Office. Edwards, N. (2010a) Deaing with the Downturn: Using the Evidence. London: The NHS Confederation. Edwards, N. (2010b) The Triumph of Hope Over Experience: Lessons from the History of Reorganization. London: The NHS Confederation. Katz, N. and Lazer, D. (2003) Buiding effective intra-organizationa networks: the roe of teams, Kennedy Schoo of Government: Harvard University. Kaber, B., Lee, J., Abraham, R., Lemer, C. and Smith, L. (2011) How pairing cinicians with managers coud speed up cinica exceence, Heath Service Journa, 22 September, pp. 21 23. Kotter, J.P. (2008) A Sense of Urgency. Boston, MA: Harvard Business Schoo Press. Locock, L. (2001) Maps and Journeys: Redesign in the NHS. Birmingham: The University of Birmingham, Heath Services Management Centre. McCarthy, S., Berman, R. and Be, L. (1993) Professionas in heathcare: perceptions of managers, Journa of Management in Medicine, 7(5): 48 55. Moore, C. (2011) Knowing me, knowing you: interpersona reationships between managers and hospita consutants, Cranfied Heathcare Management Group Research Briefing 11, May. Stace, D. and Dunphy, D. (2001) Beyond the Boundaries: Leading and Re-creating the Successfu Enterprise. Sydney: McGraw Hi. Maby, B. (2011) Suited must not mean booted, Heath Service Journa, 19 May, pp. 18 19. Øvretveit, J. and Asaksen, A. (1999) The Quaity Journeys of Six Norwegian Hospitas: An Action Evauation. Oso: Norwegian Medica Association. Pettigrew, A.M., Ferie, E. and McKee, L. (1992) Shaping Strategic Change: Making Change in Large Organizations The Case of the Nationa Heath Service. London: Sage Pubications. Pettigrew, A.M., Woodman, R.W. and Cameron, K.S. (2001) Studying organizationa change and deveopment: chaenges for future research, Academy of Management Journa, 44(4): 697 713. Waker, H.J., Armenakis, A.A. and Bernerth, J.B. (2007) Factors infuencing organizationa change efforts, Journa of Organizationa Change Management, 20(6): 761 73. 240 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 Appendix 8 Research methods Aims and backdrop The main aim of this appendix is to provide further detais concerning the data coection and anaysis methods used in this project. A further aim is to expore the wider essons from this experience for future studies of this nature. The research methods are outined briefy inchapter 1. In this appendix we go behind the scenes of the fiedwork and anaysis process in more detai. The backdrop to this project is expained in Chapter 1 with regard to the economic crisis from 2008 and the change of government in 2010. Both of those events have had a continuing impact on the funding and governance of the service as a whoe, and on the management agendas of acute trusts. Chapter 3 outines the dimensions of the institutiona context in which NHS providers operate. The emphasis in those accounts ies with the chaenges facing midde management in acute hospitas. But those trends and deveopments aso affected significanty the conduct of this research, for which funding was secured in ate 2008, with the aim of commencing fiedwork in 2009. This appendix thus aso considers how those contextua conditions infuenced the coection and anaysis of data. It was the best of times, it was the worst of times, to be conducting a study of midde management roes in acute trusts. On the one hand, managers were faced with new agendas and priorities, creating idea conditions for exporing responses to these chaenges and how manageria roes and structures were being reshaped, and identifying the new capabiities and processes that might be required. On the other hand, those new agendas and priorities generated considerabe pressures, increasing demands on managers' time and reducing their avaiabiity for research meetings. The origina project timetabe was thus abandoned from an eary stage and a 6-month extension was subsequenty required, taking this project up to the end of June 2012, rather than to December 2011 as panned. This appendix is structured in terms of the main project stages (see Tabe 1), considering the detais of data coection and anaysis, and aso exporing how the wider context of this study shaped those processes, and the essons for future research that can be drawn from this experience. We wi thus return first to the recruitment of the six participating sites, foowed by the set-up meetings, the focus groups, the management survey and finay the case incidents. To secure a measure of respondent vaidation, we aso invited participants at the six trusts to a project aunch event in 2009, to project update workshops in 2010 and 2011 and to an end-of-project conference in June 2012, as we as to a series of management briefing sessions from mid-2011 onwards. As those various events were part of the verification process with regard to the anaysis and interpretation of interview and focus group information in particuar, their contributions in this regard wi be discussed under those headings. It shoud aso be noted, however, that those events were aso offered to project participants at no cost as a courtesy, to say thank you for contributing to this study, and to maintain the reationship for future research, shoud that be appropriate. Site recruitment A ca for proposas in the area of management practice was pubished in Apri 2008. Recognising that we coud contribute to this theme, we began to pu together a project team and to approach potentia participating trusts, whie deveoping the outine proposa. As Chapter 1 indicates, the aim was to estabish a coaborative research design, and this was adopted from this stage. With a combination of corporate and persona inks with the six participating trusts, each was approached in 2008 through either their chief Queen's Printer and Controer of HMSO 2013. 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. 241

APPENDIX 8 executive or an executive board member, who were each then asked to comment criticay on the outine proposa. This step confirmed the interest in principe of those trusts in this project, and provided reassurance that the proposa was addressing themes and issues that they considered to be significant. One issue from an eary draft, concerning teamwork, was rejected as having attracted enough research and practica attention aready. The outine proposa was accepted by SDO, as was the subsequent fu research proposa, and January 2009 was the forma project start date. Each trust was thus revisited eary in 2009 to identify key contacts through whom the research team woud work, and to estabish the project ogistics in terms of distributing participant information and arranging interviews and focus groups. To gather background information about each trust, and to estabish the management groups that woud be invoved in focus group discussions and the management survey, key contacts were asked to assist in arranging a sma number of set-up interviews, as described in the foowing section. The origina project pan aowed 6 months for gaining ethica approva and for competing governance checks through the Integrated Research Appication System (IRAS). A favourabe ethica approva was granted in Apri 2009, by Cambridgeshire 3 Research Ethics Committee. The governance checks, however, were not competed unti the end of October that year; the processes appied by the Coordinated System for gaining NHS Permission CSP were cumbersome and time-consuming. Nationa Institute for Heath Research guideines at that time stated that project team members did not require research passports, given the eves of access required to hospita staff and information. One of the Comprehensive Loca Research Networks impicated in this project insisted that passports were required, again contributing to deay. A process that was expected to ast 6 months thus took 10 months, consuming consideraby more time and effort than anticipated, particuary on the part of the principa investigator. The research governance framework has since been revised and studies such as this, invoving NHS staff in their professiona capacities, no onger require the approvas that were necessary for this study. This deay was to have three consequences for data coection and anaysis. First, it was not possibe to start arranging focus group meetings with midde managers (many of whom have hybrid cinica responsibiities) during the fina quarter of caendar 2009, at the point when annua winter pressures start to mount. This meant that focus group arrangements coud not be activated unti we into 2010. Second, this had a predictabe knock-on effect on the rest of the project with regard to the timing of data coection in subsequent phases. Athough steps were taken to imit the damage, a 6-month extension was eventuay required at the end of the project. This eary deay aso affected data anaysis. It is more straightforward to anayse information, and especiay quaitative information, that has been gathered, compete, within a defined period than it is to hande information that accumuates more sowy, in an unpredictabe manner, in which the end point is uncear. Third, a degree of momentum had been ost. Having stimuated the interest of senior hospita staff through 2008 and eary 2009, having arranged interviews to gather background information and having agreed the focus group ogistics, core data coection woud not begin unti we into 2010. Some key staff had eft or changed roes in that time, one trust had appointed a new chief executive and the site recruitment process thus had to be repeated, requiring further investments of time. Set-up interviews As expained in Chapter 1, the set-up interviews (see agenda in Appendix 2) had three objectives: first, to identify the management groups who woud be invoved in the project; second, to gather background information about the trust and its management agenda; and, third, to estabish the ogistica arrangements at each site for distributing project information. In preparation for the subsequent focus groups and 242 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 management survey, interviewees were aso asked about the pressures and demands facing midde managers, about their motivations and rewards and for exampes of management contributions to cinica outcomes and care quaity. A fina question was, what has to change to aow midde managers to make an even stronger contribution?. These interviews were reativey informa, asting up to 1 hour, with the researcher taking notes that were subsequenty transcribed (no recording took pace at this stage). These interviews began with each site's ead contact, who was then asked to nominate coeagues who woud be abe to provide further background information. This process had severa benefits. First, it stimuated interest in the project among those approached. Second, the management contributions of hybrids were reinforced. Third, it confirmed the scope and chaenge of acute trust management agendas, which, apart from specific oca issues, were simiar across a six sites. Consequenty, this programme was extended, eventuay covering 93 interviewees (see Tabe 3). The transcribed interview notes were subjected to content anaysis, question by question. Content anaysis is a data reduction method, commony appied to quaitative information, and is based on identifying and categorising (coding) recurring themes. For exampe, answers to the motives and rewards question from 13 interviewees at Greenhi were coded in nine categories (Tabe 43). Simiar anayses were conducted for pressures, contributions and what has to change. These anayses were first carried out by the ead researcher for each site, and then checked by the principa investigator. The project research feow coated and further checked these anayses. There is ceary a degree of subjectivity invoved in categorising and abeing interview comments such as these, and content anaysis can be controversia for that reason. However, in this case, and as the above iustrations suggest, ony minor disputes arose over category abes, and the tabes in the main report aow readers to check whether or not the categories make sense to them. The number of items coded in each category was aso recorded, simpy to provide a rough indication of the weight of evidence being gathered; for exampe, the 13 interviewees at Greenhi identified a tota of 42 motivation items. How confident are we that this anaysis has captured accuratey the information that interviewees provided? In addition to discussion within the project team, these anayses were presented to a group of management participants from the six participating trusts at the first project update workshop in June 2010. Participants were asked whether or not they recognised these anayses as an accurate portraya of the issues; no chaenges were aunched. This step is sometimes caed respondent vaidation, a term suggesting degrees of rigour and finaity that are rarey present. However, these findings were aso presented at the second update workshop in June 2011, in 16 management-briefing sessions and at the fina project conference in June 2012, where they invariaby met with agreement. Focus groups As expained previousy, the focus group programme was deayed by more than 6 months because of deays created first by the ethica approvas and governance checks and then by the onset of winter pressures. Foowing the comments from set-up interviews, the aim was to invove four groups in particuar at each TABLE 43 Exampes of motives and rewards coding Category abe Make a difference Coeagues Hygiene factors Iustrative quote It's rewarding to work with staff groups on a concern what can we earn, what wi make a difference to patients? I work with an amazing team; deightfu peope who enjoy their jobs Leave and sick pay and pensions are generous; pay is competitive Queen's Printer and Controer of HMSO 2013. 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. 243

APPENDIX 8 participating site: cinica directors, directorate managers, ward sisters and matrons. However, where possibe, it was aso decided to invove the heads of support services departments, non-executive directors, service managers, cinica eads with service improvement responsibiities and staff in eadership and management deveopment roes. Focus group discussions foowed a topic guide (see Appendix 2) with three issues concerning motives and rewards, how management roes were changing and what woud have to change to strengthen management contributions. Group discussions were each faciitated by two members of the project team, with one guiding the discussion and the other taking notes that were subsequenty transcribed. Focus group discussions were not recorded (transcribing group conversations can be extremey difficut). Focus group discussion transcripts were subjected to the same content anaysis procedures as set-up interviews. The researchers invoved produced a first anaysis (see, for exampe, Figure 8), which was scrutinised by the principa investigator, with a focus group anayses being coated by the project research feow. A of the focus group transcripts were then recoded by an independent researcher (using a NVivo database, version 9; QSR Internationa, Southport, UK), whose choice of categories proved to be amost identica (see Tabe 42). As with the set-up interviews, the resuts of these anayses were aso presented at the update workshop in 2011 and at the fina project conference in 2012, thus increasing confidence that this anaytica approach had accuratey captured the issues raised by project participants. The ogistics of arranging focus group discussions proved to be more chaenging than anticipated. The intent was to use existing meetings where possibe, rather than arranging separate meetings and rooms. However, this invoved, for each group, identifying a meeting that an appropriate number woud be attending, at which the agenda was short enough to accommodate an additiona discussion, and where the duration of the meeting permitted this. This arrangement worked we in many instances. Some staff did not appear to meet reguary with peers (support department heads at Netherby; assistant genera managers at South Netey) and specia meetings with mixed occupationa groups thus had to be arranged. Where it was possibe to use existing meeting schedues, the research often had to wait for two or more meeting cyces to occur before an appropriatey ight agenda woud arise, and 2 months woud then eapse before that meeting coud take pace. At some sites it proved impossibe to meet with particuar groups at a during the ife of the project cinica directors and consutants at Burnside, divisiona directors at Greenhi not because of ack of interest in the study, but because of ack of diary space. A simiar difficuty at Watte Park was resoved by the research team member meeting individuay with five cinica directors whose respective diaries appeared never to share empty spaces. We have no systematic evidence but many anecdotes of midde and senior managers deiberatey and routiney doube- and trebe-booking diary sots, then hoping that one or more of those meetings woud be canceed for some reason, or making a judgement on the day as to which was the most important. One focus group meeting (Cearview) was canceed 10 minutes after it had started as participants (an operations management team) were caed to hep resove a beds crisis. These ogistica probems meant that the focus group programme, which was originay schedued to run over 6 months, actuay ran over an 18-month period. As expained above, this deayed a systematic anaysis of the coected focus group information, which was one reason for invoving an independent researcher to recode the transcripts towards the end of the project, in 2012. Nevertheess, 40 focus groups were conducted over 18 months with over 200 participants around doube the origina number of targets. The main report does not expore the contrasts across the six participating trusts with regard to the findings from either the set-up interviews or the focus groups. This is because the concusions the motives, pressures, contributions, and desirabe changes were simiar in each hospita. Management survey Detais of the survey design and administration are provided in Appendix 3, aong with an anaysis of the sampe characteristics. The majority of survey items were based on findings from set-up interviews and focus groups, and were designed to test those items with a arger sampe. As expained in Chapter 5, the 244 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 survey aso incorporated a widey adopted organisationa commitment scae, and a recognised set of stress indicators. A nove extreme jobs scae was aso buit into the design, based on focus group discussions and on a proof of concept piot, faciitated by the project's SDO management feow at one of the six participating trusts. The origina pan was to use a 60 40 design in which 60% of the survey items woud be common to a sites, with 40% taiored (by oca management) to oca issues and priorities. Ony two sites, Burnside and South Netey, took the opportunity to add a sma number of additiona items to the core survey; management at the other participating trusts were too busy in the second haf of 2011 to contempate this eve of invovement. The survey design passed through numerous iterations, within the project team, in discussion with the project advisory group and with the project's SDO management feow (an operations manager) and foowing a (hard copy) piot at one participating trust. Drafts of the design were aso circuated to the ead management contacts at each site for comment. In addition to overa item coverage and detaied wording, one of the main probems was ength: initia designs were too ong and this woud amost certainy have reduced the response rate. The fina design thus refects a series of compromises, resuting in a short instrument (70 items) that coud be competed in ess than 15 minutes. The pattern of survey responses varied widey across the five trusts that were abe and wiing to participate. Watte Park was engaged in merger discussions during the second haf of 2011 when the survey was administered and did not want the distraction of an interna management survey. Senior management at Greenhi decided, without prior consutation with the research team, to restrict the survey distribution to their 100 eaders (as part of an interna deveopment programme) rather than to the trust management popuation as a whoe. Different administration methods were considered, incuding hard copy maiing and group administration, which woud be compex and costy. The participating trusts a expressed a preference for onine administration. In some respects this was reativey straightforward. Once the survey design had stabiised, it was upoaded to the Cranfied secure server and a unique ink was created for each of the five trusts that woud participate. That ink was to be distributed at each trust in an e-mai from a senior manager (preferaby our ead contact at each site). Through this route, the research team woud know which trust the responses had come from but woud have no persona detais of respondents, other than in the repies that they provided. This approach, however, was not straightforward. Two probems arose. First, the ead contacts who were to distribute the e-mai were those same busy managers who were doube- and trebe-booking their diaries by the second haf of 2011. Inevitaby, most deegated this task to a secretary, or to a coeague with itte knowedge of this project, but who had work priorities of their own to dea with. The research team was not aways informed of these deegations. This generated deays, and some errors, in the survey distribution. Second, the issue of directing the survey to the midde management popuation of pure pays and hybrids was dependent on the e-mai distribution ists at each hospita. Those ists use other staff categories and differ from one trust to another. The maiing strategy thus had to be determined separatey at each trust, often by someone who, as just indicated, was not famiiar with the project or its objectives. Despite these probems, over 600 useabe responses were received, with an overa response rate of 24%. (The annua NHS Staff Satisfaction Survey has a response rate of around 50%.) Descriptive statistics ony are incuded in the main report, for two reasons. First, the sampe size is sma for inferentia investigation; average ce vaues fa sharpy and concusions become meaningess. Second, the pattern of responses is simiar across a five participating trusts and supports the quaitative findings, despite differences in oca conditions. Case incidents The incidents reported in Chapter 6 were based in each case on interviews with reativey sma numbers of staff who had been directy or indirecty invoved in the incidents and on the associated documentation Queen's Printer and Controer of HMSO 2013. 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. 245

APPENDIX 8 incuding statements, RCAs and timeines, investigation reports and, when avaiabe, progress reports. The evidence with respect to each incident varied significanty. The case of Mrs Mayand dated from 2005 and the Burnside C. difficie case dated from 2006, so there was consequenty a greater voume of information avaiabe concerning those two incidents (both of which had been nominated by the respective trust chief executives as incidents that it woud be usefu to study). The case of Mr Torrens occurred at the end of 2010 and events reating to that incident were sti unfoding during this project. The case of Mr Mitcham, a never event, occurred in ate 2011, as the fiedwork for this project drew to a cose. The coection of evidence concerning the atter two incidents was faciitated by the SDO management feow seconded to this project, but nevertheess, given the sensitivity and recency of those incidents, ess information was avaiabe in those cases than in the other two. As discussed previousy in this appendix, it was once again not possibe to gather precisey comparabe evidence reating to each case. Estabishing access to the staff invoved in these incidents was not probematic. On the contrary, those who were invoved mosty wecomed the opportunity to share their experiences with externa researchers (anonymousy, and in confidence). As a further indication of this wiingness to share information, the operating theatre team invoved in the Mr Mitcham case asked two members of the project team, Buchanan and Denyer, to faciitate a workshop for them on the theme of managing change in the aftermath of serious incidents. These two project team members had aready conducted workshops on this theme for severa other audiences, and Denyer had previous experience with this topic in other sectors incuding nucear reprocessing, fire and rescue services and high-security menta heath care. The arrangements were once again brokered by our SDO management feow and a 1-day (invitation ony) workshop was designed to cover three main issues: using a mess mapping too to expore incident causaity, heping the team to estabish their own change agenda and identifying and tacking the barriers to post-incident change impementation. The mess map for the Mr Mitcham incident appears in Chapter 6 (see Figure 7), aong with information from a report produced by the trust's Never Events Group, which was provided to the two researcher-presenters as background to inform the running of the workshop. This was not an action research intervention, but rather an attempt to provide assistance and support on request. Feedback from the event indicated that it was seen as vauabe, and we were invited to repeat the workshop for another theatre's team. It was understood that information coected through this process woud contribute to this project, appropriatey anonymised. We are aware, however, that the risk management team at that trust have since been considering other systems-based approaches to the overa management of serious incidents and never events. With funding for this project coming to an end, the opportunity to foow its progress in that regard has not been avaiabe. These kinds of incidents typicay unfod over proonged periods. The case of Mrs Mayand is a good exampe of this, with events and outcomes being shaped by a combination of factors at different eves of anaysis interacting over time. This suggests a narrative-based processua approach to anaysis. This has been started in Chapter 6, based on an idea narrative : an understanding of incident causaity shoud inform a change agenda, which shoud in turn trigger an appropriate change process. It appears, however, that this narrative is often edited by events and circumstances such that the change process does not occur (or is partia or deayed) and a further simiar incident occurs. The aim is to expain how and why this editing takes pace, and if possibe how to prevent this in the interests of more rapid and effective change. It proved difficut within the ength constraint of the project report to present the evidence (typicay rich and interesting) surrounding the four cases aong with more comprehensive theoretica deveopment. The weight of treatment in the report, therefore, ies with the evidence, and theory deveopment wi feature in foow-on pubications. Limitations As indicated in Chapter 1 of the main report, this study has severa imitations. 246 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr01040 HEALTH SERVICES AND DELIVERY RESEARCH 2013 VOL. 1 NO. 4 First, data coection was uneven across the six participating trusts because of the mounting pressures and chaenges facing hospita management at the time of this study, and the consequent difficuties in arranging and rearranging meetings (especiay from ate 2010 onwards). Initia pans for a common data set to be coected from each trust had to be abandoned. The information that was gathered, however, demonstrates a mutuay reinforcing interna consistency across the different data streams, which indicates that, had it been possibe to gather a more standardised set of information, the concusions woud not have been much different. Nevertheess, the ack of a common data set for each participating trust does inhibit cross-site comparisons and contrasts. Second, the extended time frame of this project potentiay jeopardises the reevance of the findings. The SDO scoping study that ed to the funding of this research was conducted in 2007 8. Pubication of the fina project report is in 2013. The NHS at the end of that period is a different organisation from the one that presented in 2007 8, in numerous respects, and particuary from an organisationa and manageria perspective. However, the pressures and chaenges facing hospita managers over this period appear not to have abated, but are continuing, and may escaate. Economic recovery in the UK is proving to be sower than anticipated, the government is sti attempting to run down a budget deficit, in part by cutting government expenditure, and as a major contributor to that expenditure the NHS is being required to continue to make efficiency savings. It is possibe that the findings and impications of this study may become more and not ess reevant in this unfoding context. Nevertheess, the timeine of this project must be a cause for concern, and this is addressed in the concuding section of this appendix. Third, coverage of the range of themes in this project reaities, contributions, changes foowing serious incidents has been achieved at the expense of depth. It was not possibe to foow up many interesting ines of enquiry because of the time pressures facing both researchers and participants. This was particuary the case with regard to some of the serious incidents, which were identified as vauabe earning opportunities in the context of the research objectives, but which woud have taken consideraby more time to document effectivey. This was aso the case with many accounts of management contributions to cinica outcomes, especiay in coaboration with cinica and/or medica coeagues, a theme that is deveoped in Chapter 7 but which merits coser attention. Nevertheess, we fee that this study has generated findings with usefu impications for organisation and management, as we as identifying a number of interesting and vauabe further research priorities. Fourth, the quantitative support provided by the management survey for the findings from the quaitative components of this study wi not satisfy a number of readers. Quaitative research in genera sti attracts suspicion (an appearance of ack of rigour is inevitabe) and is often discounted by those with scientific and medica backgrounds who are more readiy convinced by doube-bind randomised contro trias. There are a number of areas where quantitative methods woud strengthen this study. One topic, for exampe, concerns the broad range of management contributions to cinica and organisationa outcomes, with past studies tending to focus on singe metrics and assuming a more inear causa mode. Another area concerns the costs of not impementing, rapidy and effectivey, the findings from investigations into serious incidents and never events. Those costs appear to be rising, and this research has proposed more effective approaches to change impementation in such conditions. A study of this nature wi aways dispay imperfections. Nevertheess, we hope that the concusions from this research wi inform eadership and management deveopment and contributions, and organisationa change foowing extreme events, in usefu, innovative and productive ways. Lessons from this project This experience suggests the foowing four essons to inform future studies. Queen's Printer and Controer of HMSO 2013. 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. 247

APPENDIX 8 1. Coaborative research designs This research adopted a coaborative design that began with drafting the outine research proposa ong before funding was secured or fiedwork woud begin. This necessitated a series of additiona meetings with senior hospita staff, arranging project workshops and other events, responding to requests to run taiored deveopment sessions for staff groups and hoding management briefing sessions to feed back project findings. The recruitment of a SDO management feow was aso a key component of this strategy. It must be recognised that coaborative designs such as this consume consideraby more (preparation, trave and meeting) time and energy on the part of researchers than traditiona neutra observer designs. Nevertheess, the benefits significanty outweigh the drawbacks. These benefits incude a better understanding of end-user needs, perceptions and presenting probems; the engagement of participants as co-researchers and co-producers of findings; access to information that may not have appeared significant to the research team, or the existence of which the team may have been unaware; and rapid feedback on the suitabiity of materias for practitioner audiences. In addition, the NHS is a compex organisation experiencing broad and rapid changes that can be difficut for outsiders to foow. Coaborative reationships are thus vauabe in this regard, too, providing researches with insider briefings. In sum, the efforts invoved in setting up and maintaining a coaborative research design carry mutipe vauabe rewards. 2. Data coection in a high-pressure context With hindsight, it woud have been usefu to have maintained a og of the research meetings that were canceed and rearranged, ony to be canceed and rearranged again during this project. Many meetings had to be set up severa weeks, and in some cases months, in advance, and some of those were canceed and rearranged too. As pressures on management mounted in 2011 in particuar, avaiabiity for research was curtaied. It proved impossibe to arrange more than a singe meeting with a singe person on each site research visit, thus invoving consideraby more trave costs and time than had been anticipated. It was possibe in a sma number of instances to gather information through e-mai and teephone cas but, given the substance of this study, persona interviews were preferabe. The pressured nature of the context is beyond the contro of the research team. However, these predictabe deays shoud be buit into a project schedue in advance. 3. Onine survey administration Onine administration may sound ike an easy option for the busy researcher, avoiding the costs of copying and maiing, and capturing data into a statistics package. This is aso a preferred mode for most research participants. However, as expained above, ogistica probems arise. Were we to repeat this exercise, we woud (1) seek to brief in person the individuas deegated to send the e-mais and (2) arrange to be present when e-maiing took pace, to monitor when and to whom the survey was sent. Sady, this ow-trust high-contro approach seems advisabe in a high-pressure context. 4. Matching the pace of research to the pace of change Research projects unfoding over 3 years, with arge teams, can have benefits in terms of the depth with which issues can be expored and the abiity to cover a range of settings. The main disadvantage concerns the time that eapses between framing questions and pubishing answers. In a rapidy changing service, there is aso a pace for agie research, with shorter time frames and smaer teams, focusing on current and emerging themes and probems and producing actionabe knowedge quicky. Agie research need not be imited to narrowy defined issues. On the contrary, it is with the more strategic deveopments and chaenges that answers and soutions are most pressing. 248 NIHR Journas Library www.journasibrary.nihr.ac.uk

EME HS&DR HTA PGfAR PHR Part of the NIHR Journas Library www.journasibrary.nihr.ac.uk This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views expressed are those of the author(s) and not necessariy those of the NHS, the NIHR or the Department of Heath Pubished by the NIHR Journas Library