Photo – landscape with ECC

1. Photo – landscape with ECC Leadership in Challenging Times Dr Gareth Goodier Chief Executive August 2013

2. What is Leadership? “A leader is the man who has the ability to get other people to do what they don’t want to do, and like it” - Harry S. Truman “Leadership the art of getting someone else to do something you want done because he wants to do it” Harry S. Truman, American President 1945 - 1953 General Eisenhower meeting with paratroopers of the 101st Airborne Division, June 5, 1944

3. What is Leadership? “A leader is a person with a magnet in his heart and a compass in his head” - Robert Townsend “Leadership is the capacity to translate vision into reality” - Warren G. Bennis

4. What are difficult times? The last three years at Cambridge: • Relative reduction of budget >5% p.a. for that period 2009-2012 • Stringent monitoring of hospitals with penalties for poor performance

5. The Evidence! • Winner of Acute Healthcare Organisation of the Year in HSJ Awards (2008) • Dr Foster patient safety review scored 99.3/100, the only FT in EoE to get the top ‘band 5’ rating (Dec 2009) • Top hospital in Sunday Times ‘Best Places to work in the Public Sector’ (March 2010) • Joint 1st in for HSMR (RR 64.3) (Feb 2011) • Dr Foster “Trust of the year” for Midlands/East of England – based upon patient experience feedback and two measures of standarised mortality (NSMAR and SHMI) • Dr Foster “Hospital of the year” 2012 -based upon four measures of mortality and 13 measures of clinical efficiency

6. What did we do? • Strategic Decisions: • Formed Shelford Group • BI Tool development • EMR business case development • New clinically devolved leadership • Focus upon quality

7. What did we do? • Formed Shelford Group • Group of England’s leading academic teaching hospitals based on 18 measures of clinical quality, Research and Development, budget size, Foundation Trust status etc • University Hospitals Birmingham NHS Foundation Trust • University College London Hospitals NHS foundation (UCLH) • Sheffield Teaching Hospitals NHS Foundation Trust • Oxford University Hospitals NHS Trust (OUH) • Newcastle-Upon-Tyne Hospitals NHS Foundation Trust • King’s College Hospital NHS Foundation Trust • Imperial College Healthcare NHS Trust • Guy’s and St Thomas’ NHS Foundation Trust • Central Manchester University Hospital NHS Foundation Trust (CMFT) • Cambridge University Hospitals NHS Foundation Trust (CUH)

8. What did we do? • Lobbied UK Government Ministers (Treasury, Business, Innovation & Skills, Tertiary Education, Monitor, Department of Health) for increased tariff for tertiary level hospitals • Benchmarked performance • Compared savings plans • Shared ideas • Variation of Care – using information to reduce undesirable clinical variation at the level of the team and the individual medical consultant on such things as LOS (including day Rx), utilisation of diagnostics, theatre time, use of medications, harm prevention, hand hygiene etc

9. What did we do? CUH embarked on a 3 – 5 year process of transformation through which operational improvements lead to step changes that were sustained and enhanced by a major upgrade in technology. 1. Nursing Productivity 2. Medical Productivity 4. Portfolio Strategy 6. Variation of Care 5. Recording Care 7. Patient Flow 8. Utilisation of IS 9. Drugs 3. Workforce Transformation 10. Procurement & Supply Chain

10. Nursing Productivity • Ensuring optimal use of the skills and time of nurses and midwives

21. Medical Productivity • Making optimal use of the medical team skills and time • Outpatient Department patients per EFT • Operation mins per EFT (Surgery) • Discharges per EFT • HSMR by specialty

22. Workforce Transformation • Ensuring clinically devolved organisation structure • Who does what? • Medical leadership

23. Portfolio Strategy • Identifying which services should be developed, where and with whom they should be provided, and which services could be run by others • “Profit and loss” by procedure code

24. Recording Care • Improving quality of clinical records and coding, as well as ensuring the processes are in place for the hospital to be paid for the care delivered

25. Variation of Care • All observations and evidence suggest that at best there is a TWO to THREE fold variance in clinical behaviour/treatment practice across medicine. • Where there is poor clinical evidence (e.g. ADHD) the variation increases to a TWENTY fold difference

26. “The most expensive item in the hospital is the Doctor’s pen”

27. Clinical Variation In Cardiologists

28. Variation In Treatment

29. Clinical Variation In Revascularisation Coronary Coronary revascularisation procedures,per 100 000 population, 2004

30. Cataract Surgeries

31. Clinical Variation In Cataracts

32. Clinical Variation • A 23- fold difference in the rate at which children in different parts of England are • prescribed Ritalin to control behaviour… Source: Commons library/ONS, HSJ July 2008

33. Variation in prescribing OECD (2009)

34. Variation in investigations Source: OECDHealth Data 2011

35. Variation in procedure rate

36. Patient Flow • Eradicating process delays in the patient journey Length of stay reduction • Dr Foster Hospital of the Year 2012 (assessed against 13 measures of clinical effectiveness)

37. Utilisation of Diagnostics • Review and optimise ordering behaviour across the hospital • Estimated ~25% too many diagnostic investigations • By devolving budgets and cross charging, the incentive is with the clinical unit.

38. Drugs • Improving medicines management • Ensuring appropriate prescribing and reducing undesirable variation in prescribing • Antibiotic stewardship

39. Procurement and Supply • Gaining efficiencies in procurement and supply chain processes • Strengthening procurement team • Assessment of contracts and contract processes • Investigate all aspects of supply (clinical and non-clinical)

40. Leadership In Challenging Times What traits does a leader require for challenging times? • Know thyself • Focus on influencing others (particularly clinicians) • Organisation culture – clinical engagement • Know how to maximise use of information to inform change • Manage change

41. Temple of Apollo at Delphi “gnothi sauton” know yourself … Ancient Greek inscription at the Temple of Apollo, according to the Greek writer Pausanias (10.24.1) “γνωθι σεαυτόν” or

42. Influencing Others • Communication skills • Verbal, including speeches and presentations • Non-verbal • Interpersonal skills • Influencing skills • Negotiating skills • Emotional Intelligence

43. Focus on Culture Values, Behaviours, “the way we do it here…”

44. Information is fundamental Electronic Easily accessible Intuitive Real-time Reliable and accurate Detailed to patient and consultant level Available to all disciplines Used to inform decision-making, manage performance and DRIVE CHANGE

45. Benchmarked performance data • Dr Foster Intelligence • Shelford Group • Visits to ‘centres of excellence’ (eg. Southampton bus trip) The Dr Foster Unit at Imperial College, London

46. Clinical Engagement • Trust/partnership • Information systems • Training and education in management

47. Clinical Engagement • Broadly accepted that developing clinical leadership is essential to the delivery of good clinical services and healthcare reform • Variable nature and range of clinicians involved in leadership roles • Include Nurses and Allied Health Professionals engaged in clinical work

48. Leadership… “It is not the critic who counts; Not the man who points out how the strong man stumbled, or where the doer of deeds could have done better.  The credit belongs to those who are actually in the arena, who strive valiantly, who know the great enthusiasms, the great devotions, and spend themselves in a worthy cause; Who, at the best, know the triumph of high achievement and who, at the worst, if they fail, fail while daring greatly So that their place shall never be with those cold and timid souls who know neither victory nor defeat ” Theodore Roosevelt