A Mandatory Management/Leadership

Development Framework for Doctors

Professor Peter SpurgeonDirector of Institute of Clinical

LeadershipUniversity of Warwick

Enhancing Engagement in Medical Leadership

• Joint Project undertaken by National Institute for Innovation and

Improvement, and Academy of Medical Royal Colleges

• Overall goal ‘create a culture of greater medical engagement in

management and leadership with all doctors at every level’

• Two key products• Medical Leadership Competency Framework

• Medical Engagement Scale

Project Benefits

Benefits to the NHS and medical professionals include: Greater commitment and capability to effect service change and

improvement Support the drive towards the new medical professionalism Greater awareness by medical professionals of the contribution of

effective management and leadership in both operational and strategic activities

Increase and strengthen the pool of medical managers and leaders available to take on senior roles within the service

Project Products and Research

International study on preparation of doctors for leadership roles Research into the link between medical engagement and

organisational performance including Literature review Interviews with Chief Executives and Medical Directors Development of a medical engagement scale Engaging doctors publication

Medical Leadership Competency Framework

Medical Leadership Competency Framework

Describes the leadership competences doctors need to become more actively involved in the planning, delivery and transformation of health services.

The MLCF is being used to: Inform the design of training curricula and development programmes

at undergraduate and postgraduate stages of a doctors training Highlight individual strengths and development areas through self

assessment and structured feedback from colleagues Assist with personal development planning and career progression

through to revalidation The MLCF applies to all medical students and doctors

www.institute.nhs.uk/mlcf

Medical Leadership Competency Framework

Medical Leadership Competency Framework

Development of the Medical Leadership Competency Framework (MLCF) was informed by: A review of literature and key publications Comparative analysis of leadership competency frameworks Analysis of medical curricula Consultation with members of the medical and wider NHS community including

General Medical Council (GMC) Postgraduate Medical Education Training Board (PMETB) NHS Confederation NHS Employers Conference of Postgraduate Medical Education Deans (COPMeD) Medical Schools Council (MSC) British Medical Association (BMA)

Input from the project steering group, reference and focus groups, test sites and AoMRC patient/lay group.

Medical Leadership Competency Framework

Application of the MLCF will differ according to the career stage of the doctor and the type of role they fulfill. The following graphics demonstrate the emphasis that is likely to be given to the domains at each stage:

Undergraduate Continuing PracticePostgraduate

Demonstrating Personal Qualities

Doctors showing effective leadership need to draw upon their values, strengths and abilities to deliver high standards of care.

Developing self awareness: being aware of their own values, principles and assumptions and by being able to learn from experiences

Managing yourself: organising and managing themselves while taking account of the needs and priorities of others

Continuing personal development: learning through participating in continuing professional development and from experience and feedback

Acting with integrity: behaving in an open, honest and ethical manner.

Working with Others

Doctors show leadership by working with others in teams and networks to deliver and improve services.

Developing networks: working in partnership with patients, carers, service users and their representatives, and colleagues within and across systems to deliver and improve services

Building and maintaining relationships: listening, supporting others, gaining trust and showing understanding

Encouraging contribution: creating an environment where others have the opportunity to contribute

Working within teams: to deliver and improve services.

Managing Services

Doctors showing effective leadership are focused on the success of the organisation(s) in which they work.

Planning: actively contributing to plans to achieve service goals

Managing resources: knowing what resources are available and using their influence to ensure that resources are used efficiently and safely, and reflect the diversity of needs

Managing people: providing direction, reviewing performance, motivating others and promoting equality and diversity

Managing performance: holding themselves and others accountable for service outcomes

Doctors showing effective leadership make a real difference to people’s health by delivering high quality services and by developing improvements to service.Ensuring patient safety: assessing and managing the risk to patients associated with service developments, balancing economic considerations with the need for patient safetyCritically evaluating: being able to think analytically, conceptually and to identify where services can be improved, working individually or as part of a teamEncouraging improvement and innovation: creating a climate of continuous service improvementFacilitating transformation: actively contributing to change processes that lead to improving healthcare

Improving Services

Doctors showing effective leadership contribute to the strategy and aspirations of the organisation and act in a manner consistent with its values.

Identifying the contexts for change: being aware of the range of factors to be taken into account

Applying knowledge and evidence: gathering information to produce an evidence-based challenge to systems and processes in order to identify opportunities for service improvements

Making decisions: using their values, and the evidence, to make good decisions

Evaluating Impact: measuring and evaluating outcomes, taking corrective action where necessary and by being held to account for their decisions

Setting Direction

Undergraduate

• The revised Tomorrow’s Doctors released Sep 2009 includes MLCF

• Project support will include– Update to Medical Schools Council and offer support to Medical

Schools to implement MLCF– Meet with Medical School Deans to assess progress and offer advice

regarding implementation– Development of a resource and learning pack with a consortium of

medical schools– Identify minimum levels of attainment across the domains to assist in

development of appropriate assessment– Contribute to Medical Professionalism Roadshows across the UK (with

Royal College of Physicians, King’s Fund and GMC)

Postgraduate

• All Medical Royal Colleges and Faculties are undergoing a review of their curricula, PMETB has advised that the MLC is to be included in this revision.

• Project support includes:– Medical Leadership Curriculum has been developed, based on the

MLCF and provided to all colleges and faculties– Meeting with each college to discuss approach to implementation, and

how we can support this process– Providing assistance to colleges and faculties regarding assessment– Development of e-Learning for Healthcare (DH) material that will be

available to all doctors in training, regardless of specialty, in early 2010– Supporting the delivery of the new curricula with tools and support for

training clinical tutors

Continuing Practice

• Revalidation will be introduced from 2011 and the project team are working with the relevant regulatory bodies to ensure the MLCF is included in the guidelines

• Project support includes:– Meeting with SHA Medical Directors and Home Country Chief Medical

Officers to raise awareness and advise on implementation including delivery

– Contribute to review of Good Medical Practice– Work with DH, NHS, GMC and AoMRC on revalidation, providing input

on MLCF

Engagement is Critical to Organisational Performance

• Since 1997, Gallup’s extensive Q12 survey has assessed more than 4 million individuals – results revealed that of less than a third of employees (29%) are actively engaged in contributing to their employing organisations success

• In 2003 “The Quest for Quality in the NHS” (Leatherman and Sunderland) described UK clinicians as being attentive but not fully engaged in the NHS quality improvement agenda

• Successful medical engagement is crucial to future improvements in the NHS and is a policy priority with high performing NHS Trusts consistently identifying high levels of medical engagement as the key factor in achieving service improvements (Emphasised in Lord Darzi’s High Quality Care for All: NHS Next Stage Review Final Report – 2008)

• NHS organisations not only need reliable and valid tools to measure how well they engage doctors, they also need to promote and embrace a cultural change where managers and medical staff actively want to build better, more co-operative and productive relationships that drive service improvements

The Three Aims of the Research

• To develop a reliable and valid measure of medical engagement in leadership which will be quick and relatively unobtrusive to complete

• To differentiate within the scale a measure of personal engagement at an individual level (the motivation of the individual to perform in appropriate managerial and leadership roles) from the organisational context (which may foster or constrain engagement)

• To develop a systematic framework for recommending organisational strategies capable of enhancing medical engagement and performance at work

Key Assumptions of Current Approach

• Improvement in healthcare needs the positive involvement and engagement of doctors who are highly influential in planning and delivering service change

• Competence can be thought of as what someone “can do” but engagement requires a “will do” attitude

• Reliable and valid measurement and monitoring of medical engagement is critical since this will inform and shape the effective management of change

• Many definitions of engagement focus solely on individual aspect of engagement whereas the current approach also incorporates organisational conditions

• Our definition of Medical Engagement is:-

‘The active and positive contribution of doctors within their normal working roles to maintaining and enhancing the performance of the organisation which itself recognises this commitment in supporting and encouraging high quality care.’ [Spurgeon, Barwell & Mazelan, 2008]

Origins of the Medical Engagement Scale (MES)

• Applied Research Ltd. – Established large database re: attitudinal, individual & cultural aspects of NHS

• Existing measure of work satisfaction and personal commitment based on 23,782 NHS staff and 20+ health organisations

• Best items from previously established scales selected as relevant to medical engagement and re-analysed using Factor Analysis

• Scales adapted to focus on engagement - reliable, valid & relatively easy to administer & complete

Pilot Phase Focus

• Piloting took place in 4 NHS Trusts. 200-250 measures distributed, 118 medical staff returns & 19 senior managers (above 50% response rate)

• The pilot was aimed at developing a reliable and valid measure of medical engagement in leadership which will be quick and relatively unobtrusive to complete

• The measure comprised a set of items representing various scales and a behavioural checklist, enabling an assessment of the alignment between the medical and managerial perspectives

• To explore within the scale a measure of personal engagement at an individual level (the motivation of the individual to contribute to appropriate managerial and leadership roles) from the organisational context (which may foster or constrain engagement)

Scales and Definitions

Scale Definition

[The scale is concerned with the extent to which…..]

Index: Medical Engagement ...doctors adopt a broad organisational perspective with respect to their clinical responsibilities and accountability

Meta Scale 1: Working in an Open Culture ...doctors have opportunities to authentically discuss issues and problems at work with all staff groups in an open and honest way

Meta Scale 2: Having Purpose and Direction ...Medical Staff share a sense of common purpose and agreed direction with others at work particularly with respect to planning, designing and delivering services

Meta Scale 3: Feeling Valued and Empowered ...doctors feel that their contribution is properly appreciated and valued by the organisation and not taken for granted

Sub Scale 1: [O] Climate for Positive Learning ...the working climate for doctors is supportive and in which problems are solved by sharing ideas and joint learning

Sub Scale 2: [I] Good Interpersonal Relationships ...all staff are friendly towards doctors and are sympathetic to their workload and work priorities.

Sub Scale 3: [O] Appraisal and Rewards Effectively Aligned ...doctors consider that their work is aligned to the wider organisational goals and mission

Sub Scale 4: [I] Participation in Decision-Making and Change ...doctors consider that they are able to make a positive impact through decision-making about future developments

Sub Scale 5: [O] Development Orientation ...doctors feel that they are encouraged to develop their skills and progress their career

Sub Scale 6: [I] Work Satisfaction ...doctors feel satisfied with their working conditions and feel a real sense of attachment and reward from belonging to the organisation

MES Scale

MES Reliability & Validity

• Overall items reduced to 18 [or 30 for full sub-scale version] with reliability scores (Cronbach’s alpha) ranging from 0.70 to 0.93

• Inter-scale correlations with key core concepts of engagement suggest -

a) engagement is a conceptually distinct constructb) the sub-scales are important as engagement is multidimensional

• Scores from the pilot trust sites were statistically significant & in the predicted order i.e. top two are rated excellent & have taken steps to promote medical engagement, the last is in the poorest performing category & opportunistic site in the middle

MES Medical Engagement Model

FEW"Organisational Opportunities"

MANY"Organisational Opportunities"

EXPANDED"Individual Capacities"

RESTRICTED"Individual Capacities"

Doctors feelENGAGED

Doctors feelFRUSTRATED

Doctors feelPOWERLESS

Doctors feelCHALLENGED

The MES model emphasises the interaction between the individual doctor and the organisation.

The MES model emphasises the interaction between the individual doctor and the organisation.

The MES Scale Hierarchy

Climate for Positive Learning

Good Interpersonal Relationships

Appraisal & Rewards

Effectively Aligned

Participation in DM & Change

Development Orientation

Work Satisfaction

Working in an Open & Fair

Culture

Having Purpose & Direction

Being Valued & Empowered

Medical Engagement

O

I

MES Index: Position on Model for 4 Pilot Trusts

Trust C

Trust A Trust B

Trust D

Many Organisational Opportunities

Few Organisational Opportunities

Restricted Individual Capacities

Expanded Individual Capacities

Doctors feelENGAGED

Doctors feelCHALLENGED

Doctors feelFRUSTRATED

Doctors feelPOWERLESS

Meta-Scales: Position on Model for 4 Pilot Trusts

Trust A

Trust C

Trust B

Trust D

Many Organisational Opportunities

Few Organisational Opportunities

Restricted Individual Capacities

Doctors feelCHALLENGED

Doctors feelENGAGED

Doctors feelPOWERLESS

Doctors feelFRUSTRATED

Trust C

Trust A

Trust B

Trust D

Many Organisational Opportunities

Few Organisational Opportunities

Doctors feelCHALLENGED

Doctors feelENGAGED

Doctors feelPOWERLESS

Doctors feelFRUSTRATED

Trust C

Trust A

Trust B

Trust D

Many Organisational Opportunities

Few Organisational Opportunities

Expanded Individual Capacities

Doctors feelCHALLENGED

Doctors feelENGAGED

Doctors feelPOWERLESS

Doctors feelFRUSTRATED

The Levels of Medical Engagement

Embedded

Expanded

Energised

Expectant

Excluded

Doctors are fully involved at all levels in leading the design and delivery of service innovations

Doctors traditional roles have become expanded to embrace some aspects of managing healthcare

Doctors are keen to become more involved in the planning, design and delivery of services

Doctors understand the importance of becoming involved in the management agenda

Doctors are not part of the management process and confine their activities to their traditional roles

Engagement Intervention Strategies

The IHI Framework for Engaging Physicians in Quality and Safety – Reinertsen et al (2007) - comprises six areas which can be used as a checklist for engaging physicians in quality and safety.

In a similar way the hierarchical structure of the MES has also been linked to suggested potential intervention strategies and these are outlined in the hierarchical figure shown. 

1.2.2

Promoting Positive

Participation

1.2.1

Promoting Individual and Organisational

Alignment

1.3.1

Promoting Leadership

Development

1.1.2

Promoting InterpersonalEffectiveness

1.1.1

Promoting an OpenLearningClimate

1.3.2

Promoting Job

Satisfaction

1.1

Promoting an Authentic, TrustingCulture

1.2

Promoting Common

Purpose and Direction

1.3

Promoting Motivation and Empowerment

1

Promoting Broad System Engagement

LEVEL ONE -FUNDAMENTAL INITIATIVE

LEVEL TWO -FOCUSEDINITIATIVE

LEVEL THREE -FIXEDINITIATIVE

PROMOTING MEDICAL

ENGAGEMENT

LEVEL AND TYPES OF INTERVENTION INITIATIVES

A LEVEL ONE change strategy tends to be FUNDAMENTAL since efforts to improve professional engagement at this top strategic level usually have the potential to impact upon any of the lower levels of the intervention hierarchy.

A LEVEL TWO initiative is described as FOCUSED since efforts to promote professional engagement at this level may still be broad in aim but are typically designed to enhance one of the three domains of engagement (i.e. engagement as relationship, involvement or motivation).

A LEVEL THREE intervention is described as FIXED because it is specifically aimed at one of the six distinct factors that have been shown to underpin professional engagement.

Levels of Medical Engagement Summary for Trust 1

Climate for Positive Learning

Good Interpersonal Relationships

Appraisal & Rewards

Effectively Aligned Participation

in DM & Change

Development Orientation

Commitment & Work

Satisfaction

Working in an Open &

Fair Culture

Having Purpose & Direction

Being Valued & Empowered

Professional Engagement

O

I

HIGH

HIGH

HIGH

LOW

MEDIUM

HIGH

HIGH

HIGH

HIGH

HIGH

Medical Engagement Scales:

Relative Normative Feedback Trust 1

KEY

High Relative Engagement (Top 1/3rd Trusts)

Medium Relative Engagement (Middle 1/3rd Trusts)

Low Relative Engagement (Bottom 1/3rd Trusts)

Levels of Medical Engagement Summary for Trust 28

Climate for Positive Learning

Good Interpersonal Relationships

Appraisal & Rewards

Effectively Aligned Participation

in DM & Change

Development Orientation

Commitment & Work

Satisfaction

Working in an Open &

Fair Culture

Having Purpose & Direction

Being Valued & Empowered

Professional Engagement

O

I

LOW

LOW

LOW

HIGH

HIGH

HIGH

MEDIUM

MEDIUM

MEDIUM

MEDIUM

Medical Engagement Scales:

Relative Normative Feedback Trust 28

KEY

High Relative Engagement (Top 1/3rd Trusts)

Medium Relative Engagement (Middle 1/3rd Trusts)

Low Relative Engagement (Bottom 1/3rd Trusts)

Levels of Medical Engagement for All Trusts in Current Sample

Engagement Meta Scale 1 Meta Scale 2 Meta Scale 3 Sub Scale 1 Sub Scale 2 Sub Scale 3 Sub Scale 4 Sub Scale 5 Sub Scale 6

Trust 1 6 10 4 7 4 23 7 3 11 7

Trust 2 15 24 13 11 23 21 20 8 12 10

Trust 3 26 23 26 26 20 22 26 23 26 25

Trust 4 22 20 22 14 22 14 23 12 16 13

Trust 5 4 4 5 4 6 5 5 6 5 4

Trust 6 11 5 17 19 7 4 14 21 13 19

Trust 7 12 9 18 15 13 6 13 25 9 23

Trust 8 27 26 28 28 26 26 29 26.5 28 28

Trust 9 19 22 10 23 15 27 10 10 27 17

Trust 10 7 6 6 10 5 12 15 1 22 6

Trust 11 10 11 9 13 8 15 8 11 19 9

Trust 12 2 2 3 1 2 1 3 5 1 2

Trust 13 14 15 16 12 19 10 11 26.5 8 18

Trust 14 9 7 8 8 10 9 6 13 6 12

Trust 15 3 3 2 3 3 8 2 4 4 3

Trust 16 8 8 11 6 9 11 16 7 10 5

Trust 17 20.5 14 23 17 11 20 22 20 17 16

Trust 18 29 29 29 29 29 25 28 29 29 27

Trust 19 18 17 20 16 18 13 25 9 21 11

Trust 20 30 30 30 30 30 30 30 28 30 30

Trust 21 1 1 1 2 1 2 1 2 3 1

Trust 22 23 25 19 20 25 24 18 19 14 21

Trust 23 24 21 25 24 22 16 24 24 24 22

Trust 24 5 12 7 5 12 7 4 17 2 8

Trust 25 20.5 16 15 21 16 17 19 16 23 20

Trust 26 28 28 27 27 28 28 27 22 25 29

Trust 27 16 13 14 22 14 18 12 15 18 24

Trust 28 17 18 24 9 27 3 17 30 7 14

Trust 29 25 27 21 25 24 29 21 18 15 26

Trust 30 13 19 12 18 17 19 9 14 20 15

Contact Details

Professor Peter Spurgeon

Professor of Health Services Management

p.c.spurgeon@warwick.ac.uk

Website: www.institute.nhs.uk/medicalleadership

Email: medicalleadership@institute.nhs.uk

© Copyright 2008 NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges