Engaging clinicians in quality improvement

Health managers and clinicians in healthcare are dedicated professionals working in an increasingly demanding and complex world. Their end goal may be the same but tensions in the relationship can threaten progress in driving forward service improvement to improve patient outcomes.
The Griffiths Report of 1983 heralded the age of general management in the NHS. A move towards managers having operational control at every level of the organisation and relieving clinicians of strategic responsibility was seen as the way to transform health care to resemble successful private and commercial organisations.
However, along with an endless cycle of reforms since then, there has been a change in emphasis. In more recent years, increasing importance has been placed on clinicians working in multidisciplinary teams and across professional and organisational boundaries. Indeed the High Quality Care for All (2008) report from Lord Darzi put clinical leadership at the heart of improving the NHS.
This move is supported by a growing body of evidence highlighting that clinical leadership improves quality and outcomes for patients (Mountford and Webb, 2009). Veronesi et al (2012) found that those NHS hospital trusts with larger proportions of doctors on their boards were more likely to achieve high quality ratings, lower morbidity rates and higher patient satisfaction.
Evidence also shows a clear link between an organisation’s performance and a good level of engagement between clinicians and managers (Medical Engagement Scale; NHS Institute of Innovation and Improvement, 2010).

Different worlds
In its 2007 review of the literature on healthcare professionals’ views on quality improvement initiative - Are clinicians engaged in quality improvement? - The Health Foundation noted: “Different health professional groups largely inhabit separate hierarchies and networks, often with surprisingly little inter-communication”.
The need to change this may have been recognised but making better communication a reality is not as easy as it sounds. This is particularly true during periods of reform. The NHS is almost constantly re-inventing itself as it teeters on the edge of a financial crisis and struggles to meet the challenges of an aging population with costly co-morbidities.
Structural change within any organisation almost invariably leads to tensions and one of these strains has been on the relationship between clinicians and managers, which has been described as ‘fraught’ and ‘tense’ (Health Service Journal, 2012).
A small survey of just over 200 managers carried out by IHM recently suggests that, in some areas at least, this remains the case. Nearly three-quarters of managers (73 per cent) said they thought the relationship between the two groups of professionals could be defined as ‘a partnership with areas of tension’ or ‘a relationship of tolerance with frequent tensions’. A similar number (73 per cent) thought the relationship would stay the same or get worse over the next five years.
The existence of tension is hardly surprising as, despite their common goal, the context, structure, parameters and limitations that both set of professionals work within are very different.

Making partnership a reality
An organisation as large and complex as the NHS cannot be run without high-quality management and leadership, and people in those roles must be trained, empowered and valued whatever their background. So how do we make this happen?

Clinicians and managers have both highlighted a number of facilitators to fostering a positive relationship. They include; trust, mutual respect, support, accessibility, visibility, good communication, close proximity, mutual interdependence and friendship (HSJ, 2012). None of these, however, can be plucked out of thin air and the IHM is making a number of ‘calls to action’.
One of these is for clinicians and managers to explore each other’s roles and responsibilities through paired learning and shadowing initiatives, such as those piloted at Imperial College Healthcare NHS Trust during 2010-11. Clinicians and managers were invited to spend time learning about each other’s roles and responsibilities.

Enhanced engagement
The initiative aimed to create a better understanding and new ways of working between clinicians and managers; support the personal development of each of the participants in achieving specific educational objectives around leadership and management and create an environment where enhanced engagement between clinicians and managers was role-modelled within the organisation.
An evaluation of the programme in 2012 stated that paired learning had ‘significantly increased preparedness for leadership roles for both Specialist Registrar doctors and managers across a wide range of domains’. The qualitative analysis demonstrated that the co-development of managers and doctors had ‘a powerful impact on the personal learning, attitudes and behaviour of participants’.
IHM believes that this is the way forward, supported by joint management training programmes and events. Clinicians, like managers, need development and support. Just over half of respondents to the IHM survey felt that currently clinicians in the NHS lack the management experience to make the right decisions. They suggested that they would benefit, in particular, from training in leadership and accountability, people and line management, performance and appraisal, and operational and business planning.
It is worth noting that current thinking on managerial effectiveness emphasises managerial behaviours, not just competencies, which was the state of play in the 1990s. This is why the IHM has introduced its Professional Practice Framework which provides a way to establish common core values and behaviours that healthcare managers demonstrate on a daily basis and that are an integral part of the service re-design and transformation needed to improve the public’s health. It is equally applicable to clinicians as, increasingly, they move into management roles.

Closer working relationships
IHM believes that the involvement of doctors, nurses and other clinicians in leadership roles, working closely alongside their managerial colleagues, must be a priority for the current and successive governments. The ultimate beneficiaries of closer working relationships between managers and clinicians will be the patients. Improved patient care is - and always has been - the shared ground.

Further information