Ombudsman

Northern Ireland

CURRENT CHALLENGES FACING MEDICINE AND

MANAGEMENT

29th May 2007

Dr. Tom Frawley

May you live in interesting times

- A Chinese curse

Uncertain times – a context:

• Bristol Royal Infirmary • Dr Harold Shipman• Beverley Allitt• Dr Michael Neary• Sperrin Lakeland• Organ Retention• Endoscopes• Mammography United Hospitals

Choice…

How to behave:• Survival• Adaptation• Skills• Learning

The Patient-Doctor Contract

In the past:

“They give their time, training and expertise and expect in return to get autonomy, deference, respect and job security”

…“To give and get”…

The Patient-Doctor Contract

Now, however:

“Greater accountability, more assertive and better informed patients, a need to collaborate with other professions, and constant evaluations, inspection, audit and even regular reviews of their competence to practice”

Clinical Interventions• Maintain Life• Restore Health• Prevent harm• Reduce Risk• Enhance safety

The Reality - harmful consequences are more common than we recognise

• 10% in-patient admission – adverse event• 5% population report adverse effect of medical

care• 18% of patients report being victim of medication

error in previous 2 years

• Manage expectations

Medicine: A Challenging WorldSir Brian Jarman• 240,000 out of 610,000 deaths – some 40% -

occur in hospital• 12% - some 28,000 – of these hospital deaths

caused by avoidable adverse events• Large (4x) variation in death rates between

hospitals:• Best 400 fewer than average• Worst 200 more than average

• Where is Northern Ireland/Irish Health Service?• Where is your hospital• Where is your specialty

• People gain access to services more quickly – NHS Direct and walk-in Centres

• People waiting more than six months for admission as In-patient - down by 85%

• Drop in number of people waiting more than 13 weeks for an appointment as an Out-patient – down by 92%

England & Wales Health Service Performance

England & Wales Health Service Performance

• Improvements in outcomes of care and treatment for people with coronary heart disease or cancer

• Mortality rates for cancer have gradually decreased

• More than 50% of people who have a heart attack receive clot busting drugs within an hour – 84% receive them within 30 minutes

Healthcare Commission Survey of NHS Patients in England (May 07)

• 93% said room or ward ‘clean’ or ‘very clean’• 84% said they waited 6 months or less for planned

admissions• 20% of patients who needed help eating said they did

not get enough• In 30 Trusts 20% rated the food as ‘poor’; in most other

trusts few rated the food as ‘poor’• In planned admissions, not to critical care units, 11%

said they shared a room or bay with a patient of the opposite sex

How would the Republic of Ireland perform?

N.I. Health Service Performance

• Hospital activity per member of staff 19% lower than UK• Hospital activity per available bed 26% lower than

England• 43% more admin staff than in England• Average unit prescribing costs 30% higher in NI• Significant variations in unit Trust costs in NI• Major variations up to 25% in £ allocated to communities

in NI• Considerable unused capacity, for example, in operating

theatres• R.O.I. Health Service Performance?

“Need for greater scrutiny, medicine used to be simple, ineffective and relatively safe. It is now complex, effective and

potentially dangerous. The mystical authority used to be

essential to practice. Now we need to be open and work in partnership with our colleagues in health care and with our

patients”

Cyril Chandler, Dean of Kings College Medical School

LEADERSHIP AND

MANAGEMENT

Shift Happens!

GREATER SUCCESS+

at GREATER SPEED+

with CONSTANT UNCERTAINTY

+with LESS RESOURCE

+with MORE

COMPETITION

Our world of work

Who wants to play?

Unprecedented Change

SOCIAL CHANGE POLITICAL CHANGE

TECHNOLOGICAL CHANGE

ECONOMIC CHANGE

Positive Drivers of Change:

• Changing Public Expectations• Patient Knowledge (Internet

and Media)• New and improved technology• Patient Choice• Additional Funding

Public criticisms:

Public criticism of clinical professionals:• Tolerance of poor practice• Secrecy about professional’s performance• Poor communication• Paternalism• Insufficient accountability• Regulation not sufficiently open and

transparent

What the NEW PATIENT expects:

• Accessibility

• Knowledge – generalist and specialist

• Skill – holistic approach

• Empathy

• Care

• Effectiveness

• Leadership

What the NEW PATIENT deserves:

• To be treated as a partner

• Not to be seen as compliant and submissive

• To be given the information required for truly informed consent

• Thoracic surgery example.

Patients a sense of:PowerlessnessFrustrationFear

Culture eats strategy for breakfast

The Patient Perspective

The experience is the outcome: Hardwire patient experience

Hitting the targets: Missing the pointArchie Cochrane: Rocking the patientListen; Spend time; Hold hand

“Neither a brave man nor a wise man lay down on the

tracks of history to wait for the train of the future to run over

him.”

Dwight D Eisenhower

Is everyone a Leader?

• Those who make things happen

• Those who think they make things happen

• Those who watch things happen

• Those who wondered what happened

• Those who didn’t know anything happened

Leadership Competencies:

• Strategic awareness

• Customer orientation

• Quality creativity

• Ethics

• Individual accountability

• Team playing

• Communication skills

Leadership

• Is difficult to define - virtually impossible to measure objectively and cannot be taught in schools

• However, the quality of leadership is the most important ingredient in the recipe for the success of an organisation

• It is the ability to inspire other people to work together as a team, following your lead, in order to attain a common objective

Leadership

• No one can do it all alone – others must

want to follow the leader

• Leadership is learned - the ability to lead

and inspire others is far more instinctual

than premeditated and is acquired through

the experience of everyday life

Leaders v. Managers

1. The manager administers;

The leader innovates

2. The manager has a short-range view;

The leader has a long-range perspective

3. The manager asks how and when;

The leader asks what and why

Leaders v. Managers

5. The manager has his eye on the bottom line;

The leader has his eye on the horizon

6. The manager accepts the status-quo;

The leader challenges it.

Warren

Bennis

The Essential Tasks of Leadership

• Tune into the environment, see need, opportunities: Encourage curiosity that opens our eyes to new possibilities not just about problems

• Be dissatisfied, generates fresh thinking. Creativity, find new approaches, dig beyond where we are, identify new possibilities, approaches

• Anticipate a vision that will mobilise people to act. Change begins with hope. Get other people to see it too. To pilot is important – dream. Small steps important.

• Coalition building, cross boundaries – ‘water walkers need stones’

The Essential Tasks of Leadership

• Find, recruit, identify the team that will make it happen. A dream needs to brood.

• Persevere until you wear down the middles – have passion. You can run out of time and money.

• Forecasting is difficult if you are doing something unique.

• Run into obstacles. People get tired, that is when critics emerge.

• Separate lines.

The Essential Tasks of Leadership

Leadership is Key

Leaders must ignite:PassionPaceDrive

Leaders must Build Common Purpose

Drivers for Today’s Workforce

Emotional: being involved in ones workCognitive: focussing hard while at workPhysical: being willing to go the extra mile

Engaged Staff: Feel positive about job: Perform better

• Make heroes of everyone, appreciate, recognise and acknowledge everyone. Say ‘thank you’. No one wants leaders, they rise also to the challenge. Energy

• Communicate, communicate, communicate…

The Essential Tasks of Leadership

Follow Leaders because they want to

Human beings powered by emotion

Ambiguous Leadership

Staff -

Managing Informal System

“Dolly the Leader”

Nurses in charge of mood of patients

“Cultural Blackspots” – dominated by harassment and bullying

AN EFFECTIVE COMPLAINTS

SYSTEM

Complaints:

Real time insight.

Building an Effective System• Focus on rights of Patients

• Right to safe treatment

• Importance of good record keeping

• Importance of good communication - Between Clinical staff - Between Clinical staff and

patients/ families

Acknowledging Mistakes…

• Openness is a precondition for learning

• Complaints, changes and mistakes are logged and replayed

• Mistakes are acknowledged, even celebrated as a source of information

• Everyone does better in future• A “learning organisation” develops

In Summary• A whole system:• Strong compliance to a uniform

system• Rooted in local resolution• Independent 2nd level – other than

body complained of• Ombudsman final recourse

An Effective Complaints System

Easy to access;Fair;Flexible;Ensure confidentiality;Clear andTimely;Integrated with other systems to provideValuable Feedback; andEngender trust from service users and staff

10 Tips for Dealing with Complaints

1. Keep it simple2. Use the phone more – don’t

automatically write3. Find out what the complainant wants you

to do4. A quick apology can be better than a

long letter5. Give personal and specific replies

10 Tips for Dealing with Complaints

6. Follow the ‘mother principle’ 7. Don’t pass the buck8. Be clear what solutions you can offer9. Let people know about improvements

you make as a result of complaints10.More complaints can be good news! It

shows your customers trust you to take them seriously

The Rights & Responsibilities of Complainants

Rights ResponsibilitiesFair treatment Provide timely info in support of

complaint

Courtesy Provide accurate info in support of complaint

Timely response Treat organisation staff with respect & courtesy

Accurate advice Adopt reasonable & open-minded attitude

Respect for privacy

Reasons for decisions

Key elements of an effective complaints system…

The Core Values That Inform Our Work

Independence

Integrity

Impartiality

To give life to these core values we treat people with courtesy, consideration and honesty; And respect their privacy

Benefits of effective complaints system

• Identifying areas for improvement

• Creating a ‘second chance’ to provide the service and satisfaction to dissatisfied clients

• Leading to….

• Strengthening public support for the system of public service delivery

Designing Effective Complaints Systems

• Go the extra mile

• Make the service personal

• Deliver on promises for the system

• Deal with complaints as well as we possibly can

Why we need complaints systems…

Working in the PUBLIC service means…

• Accountability

• Especially to those who are dissatisfied

• People have a RIGHT to complain

• Responsibility

• People do not have a choice

• Guard against insensitivity

Why we need complaints systems…

BUT it doesn’t mean…

• We are immune to changes in society

• People may not have choice, but they do have

expectations

• Expectations are changing

Why we need complaints systems…

Change in Public Expectations…

• Accessibility and choice• Responsiveness• Effectiveness and safety• Openness

• Transparency

• Increasingly comparing public sector service with private sector service

Why we need complaints systems…

Change in Government Policy…

• Readiness to adopt radical solutions to issues

of service delivery

• Public Sector may be guaranteed first crack at

solving problems, but what if fail?

• Increasingly looking to private sector for

solutions to public service delivery

“Old borderlines are evaporating, old categories are merging. The divisions between commercial, public-sector and non-profit organisations are becoming blurred. All organisations now act on the same stage, and need to justify their place on that stage.”

The Big Idea – Robert Jones

Why we need complaints systems…

So… why do we need complaints systems?

– Because we are obliged to be accountable

– Because society is changing

– Because Government policy is changing

– BECAUSE WE NEED TO “UP OUR GAME”

Why we need complaints systems…

Accountability

• Accountability must be provided to citizens and users of public services, especially those who are dissatisfied

• Citizens and users have a right to complain

• Accountability- a complex and multifaceted concept

• More than discharging responsibility

Accountability

• If actions to obey instructions- to be accountable requires only the report that these instructions have been obeyed

• If actions require the exercise of discretion (to make choices, take decisions)- to be accountable also requires an explanation

Accountability

• Public officials are accountable for:– the results or outcomes of their actions– the professional standards of their work– the effective use of resources, including

financial resources

• If users of system feel service has fallen short of expectations- system needed to address deficiencies

• Complaints system

The Importance of Ethics

• Ethics must inform all of the fundamental values that determine our professional and personal behaviour

• Ethics is concerned with:– honesty– fairness– justice– respect for others– making us think about the impact of our

behaviour on others and, by extension, our reputation

The Importance of Ethics

• Shouldn’t see ethics as a ring-fenced boundary

• Not a set of mechanical, abstract rules to be wheeled out and applied to some abstract circumstance

‘For our discussion is about no ordinary matter, but on the right way to conduct our lives’

Plato

The Importance of Reputation

• Reputation is a precious commodity

• Takes a lifetime to build, can be destroyed in a moment

• Once reputation is lost, it can be incredibly difficult to rebuild, if not impossible

Key issue - risk to reputation

• Common theme from case studies where reputation is lost– denial (Randall 2007)

• Typical chain of events leading to reputational catastrophes (Wharton School, University of Pennsylvania):

• There’s an initial mistake, often minor, that goes uncorrected;

• A subsequent error compounds the initial error;

• Attempts to correct the problem are often half-hearted, either because there is no recognition of the increasing seriousness of the situation, or executives are in denial;

• When the problem eventually becomes too big to ignore, attempts are made to hide the truth; and

• There is an awful moment of acceptance that the situation is completely out of control

Words to live by…

I Have Seen the Enemy

And He Is Us

• A belief that what we are doing is important

• An empathy for the people we work with and work for

• The certainty is change• A sense of humour

When You Point Your Finger At Someone There Are Three

Fingers Pointing At You

“Things Do Not Change;

We Change”

Henry David Thoreau

Final Thoughts!

Nothing in life is certain

The public is often (very) demanding

Those with the least to complain about often complain the most and those with the most to complain about

often complain the least

Simple courtesies can make a big difference and the word sorry can transform the circumstance

“It should be borne in mind that there is nothing more difficult to arrange, more doubtful of success, and more dangerous to carry through than initiating changes in a State’s arrangements.

“The innovator makes enemies of all those who prospered under the old order, and only lukewarm support is forthcoming from those who would prosper under the new”

Machiavelli