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Nederlandse Tropen Cursus NTC & Core Course MIH Daily management and training. Daily management of a health facility Pieter van den Hombergh IQhealthcare Working party On Q of Care Research LHV Dutch Association of GPs. Program Wednesday 12-5-2010. Morning 9.00 - 10.00 Introduction

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nederlandse tropen cursus ntc core course mih daily management and training
Nederlandse Tropen Cursus NTC & Core Course MIHDaily management and training

Daily management

of a health facility

Pieter van den Hombergh

IQhealthcare

Working party On Q of Care Research

LHV Dutch Association of GPs

program wednesday 12 5 2010
Program Wednesday 12-5-2010

Morning

9.00 - 10.00 Introduction

10.00 - 11.00 Analysis of Kilgoris, a LIC health facility

Coffee

11.00 –12.00 Practicing management skills

Lunch

13.00 – 13.30 Making plans

13.30 – 14.00 ABC-drill

14.00 – 15.00 Practicing ABC

15.00 – 15.30 Evaluation & Final slides

management of the organisation is quality of care
Management of the organisation is quality of care

patient

Physician A

Surgeon B

Matron

Nurse A

Midwife B

Tutor

what is management
What is management?

To enable people

to perform jointly

creating the required conditions

Conditions:

  • Joint goals and values,
  • Training and guidelines
  • Structure
  • Leadership: Pusher, Puller, Player, Pleaser
the professional
The professional
  • Shows creative and independant thinking
  • Has experience, craftmanship & knowledge
  • Sticks to professional values and guidelines

But is a hopelessly unguided missile.

quality improvement why practice management

QUALITY IMPROVEMENT Why practice management?

Improvement of

practice management

=

80%

of all possible improvement

in health care

management field description main categories in a health facility
I Infrastructure

II Team

III Communication

IV Finance

V Quality of care/

Safety

Premises, equipment

Service, Accessibility

Doctor’s bag, First Aid

Delegation, job mix

Workload, Jobstress

Patiënt records, staff

Network of care givers, ICT

Year-report

Certification, Innovation

QI, protocols etc.

Management Field descriptionMain categories in a health facility
organisation analysis2
Organisation analysis

Urgency

&

Cohesion

urgency
Urgency

Choose from your heart

=

The fuel for performance

Elastic band

Creativity Stress

What I want? Reality

urgency1
Negative if:

Goal is sky high

Goal is not realistic

Time is short

Urgency depends on someone else (boss)

Negative urgency causes stress, is tiresome

Positive if:

Goal is tickling

Goal is realistic

Well planned in time

Is well perceived by you, comes from your heart

Positive urgency is inspiring, creative & gives energy

Urgency
different organisations
Bureaucratic

Formal, values + guidelines

Supervision by superiors

Standardisation of tasks

Authority based on social order

Fit for e.g. passport

Professional

Autonomous, creative

Supervision by colleagues

Standardisation is a problem

based on knowledge and skills

Fit for advertisement bureau

Different organisations
model of mintzberg
Model of Mintzberg

Structure

=

the way

the organisation

has divided work in tasks

and

the way

it coordinates these tasks.

professional organisation
Professional organisation
  • Professional burocracy
  • Too many professionals
  • Too little support
  • Difficulty in standardisation
  • Small top
without mission vision
Without MISSION & VISION

is

each question, each daily problem, each situation

a confrontation

with the lack of

common purpose

setting goals objectives

Setting goals / objectives

The importance

of an

explicit, clear and transparant

GOAL

importance of setting goals
Importance of setting goals
  • Powerful management-instrument
  • Noses in the same direction
  • Clarifies the problems
  • Can be evaluated
  • Can be split in parts
  • Is communicable
  • Motivates
smart objectives

SMART Objectives

Specific

Measurable

Achievable - Aantoonbaar

Relevant

Time-limited- Tijdgebonden

care what is optimal
CARE What is optimal?
  • Tb
  • Smoking
  • AIDS
  • Blindness

Patient

demand

True needs

Demand

optimum

Supply

Doctors, Hospitals, Local healers

reflection
Reflection

Clinical effectiveness

TransparancyAccountability

Reward

from goal to strategy
From goal to strategy

data

year-report

policy- advice

SWOT-ANALYSIS

GOAL

STRATEGY

THE ENVIRONMENT

threats opportunities analysis
Threats & opportunities analysis

Demographic, political & economic developments

Dispensaries

Hospital

Community

District health

authority

Health

facility

Church

Drugs supply

Colleagues

Training centre

Referral hospital

Social, technological & communication developments

management skills
To motivate

To analyse

To communicate

To delegate

To negotiate

To direct, guide

To think, make an inventory

To inform

To plan

To use power

MANAGEMENT SKILLS
in the pursuit of quality of care
IN THE PURSUIT OF QUALITY OF CARE

every defect

is

a treasure

managing
Managing =
  • Choose
  • Commit yourself
  • Be reliable, trustworthy, true to yourself consistent, not letting people down.
  • Know your strengths and weaknesses

This how you show

integrity and respect for yourself!

managing not manipulating
Managing = not manipulating
  • Think in win – win (not I win you loose)
  • Don’t give up on integrity
  • Check intentions and consult your conscience
  • A goal never justifies the means
  • Only want, what can be done
good clinical governance
Good Clinical Governance

=

Sum of

Quality Improvement

&

Accountibility

management skills1
Analyse

Thinking in problems

MANAGEMENT SKILLS
management skills2
Analyse

Communicate

Thinking in problems

MANAGEMENT SKILLS

openness

open communic ation
OPEN COMMUNICATION
  • Systematic approach in the consultation
  • Don’t think in solutions, avoid jumping to
  • Listen open, don’t judge
  • Try to get the whole picture first
  • Encourage with ‘hmm’, ‘o yes’
  • Check
management skills3
Analyse

Communicate

Motivate

Delegate

Leadership

Plan

MANAGEMENT SKILLS
motivating people
Motivating people

People do not get tired of

working hard,

but they do get tired of

lack of purpose and lack of power.

to motivate
TO MOTIVATE

Motivating elements

  • Their own tasks with
  • Responsibility
  • Time for consultation
  • Consultation at an early stage
  • Passing on knowledge and skills
  • Appreciation and positive feedback
to demotivate
TO DEMOTIVATE

Demotivating elements

  • Working place is awful or not available
  • Too little responsibility
  • Too litle time for consultation
  • Vague tasks & agreements
  • Starting late
  • Finishing late
to deleg ate
TO DELEGATE

CONDITIONS FOR PROPER DELEGATION

  • Motivation of the staff
  • Competence of the staff
  • Supervision
  • Presence of the supervisor
  • Space for the delegated tasks
  • Informed consent of the patient
to deleg ate1
TO DELEGATE

ACCEPTANCE BY THE PATIENT

Better acceptance, when

  • staff is licensed
  • staff is supervised
  • staff has experience
  • staff does other tasks as well
  • Staff has autonomy and professional charter
giving feedback
GIVING FEEDBACK
  • Start with the good things
  • Be factual, descriptive
  • Be specific
  • Discuss behaviour that can be changed
  • Offer alternatives
  • Be owner of the feedback
  • Feedback discloses your motives
receiving feedback
RECEIVING FEEDBACK
  • Listen first, don’t reject, don’t argue, let it sink in
  • Ask for clarification, when necessary
  • Check the feedback with others
  • Ask for the feedback you want
  • Determine beforehand what you want to do with the feedback
management skills4
Analyse

Communicate

Motivate

Delegate

Organise

prepare

MANAGEMENT SKILLS
management skills5
Analyse

Communicate

Motivate

Delegate

Organise

MANAGEMENT SKILLS

Evaluate

= Check

the management cir cle
THE MANAGEMENTCIRCLE

Setting goals

Observe Analyse

Think

Ask Plan

Evaluate Organize

Implement

Coordinate, motivate

plan treatment cq admission room
PLANTREATMENT cq ADMISSION ROOM
  • Problems
  • Insufficientlight
  • Parentsfill the room
  • Admission room givesalsoaccess to treatment room
  • Nurses are alwayspresent doingothertasks
  • Concentration of staffsuckspatients; That was whereithappened.
  • At the end of a daypeople are more grumpy.
  • Treatment room toosmall in times of Malaria/meningitis
  • Admission room toosmallwithtoomanypurposes.
  • Advantages
  • "Relatives" were in treatment room behind the "slab", withchild
  • Staffkeptaneyeonseriouslyillchildrenduringadmissioon
  • Equipment present duringadmissionfortreatment (LP, IV, O2)
  • The treatment room had sufficientlight
slide50
PLAN

Doing the

right things

Doing the

right things

right

PLAN

slide52
PLAN

Strategic Operational

Doing the

right things

Doing the

right things

right

PLAN

Effectivity Efficiency

slide53
PLAN

Strategic Operational

design

plan

Doing the

right things

Doing the

right things

right

choose

act

do

observe

analyse

check

Effectivity Efficiency

abc drill
ABC-drill
  • Aexplains toBhis objectives (goal, problem, plan). He does that systematically, giving A a brief outline of his practice profile
  • B listens actively and communicates openly
  • Cis in charge of the process and the time (15 min) and makes notes. 5 Minutes before time C askes A and B to report on the process and C gives feedback
slide56
A
  • AtellsBwhat A’s vision is of the future practice and how that fits into A’s personal life plan.
  • What are A’s objectives formuled SMART, clear and open to B.
  • A informs B systematically.
  • A gives a practice profile to B and C
  • A invites B to ask critical and explorative questions
  • Don’t discuss, you waste time
  • A asks Bfor an honest opinion
b mckinsey
B = McKinsey
  • B communicates open, without judgement
  • B tries to get a finger behind A’s problem
  • B doesn’t give advice, doesn’t solve A’s problems
  • Use helpful questions:
    • What does A want to realise in the short/long term?
    • Why does A have that vision, What are A’s intentions?
    • For who, with whom does A want it?
    • What does A’s plan solve?
    • What is A’s problem?
    • How do I see A’s problem?
slide58
C
  • C listens, makes notes, correctsAandB
  • C checks the time and is chairman
  • C guards the process
  • C gives feedback in the last 5 minutes
  • Caskes AandBto report on their perceptions
    • Feedback is factual, specific, clear
    • Tell what you saw and heard without judgement
    • Check your feedback. Was it correct?
check your plan
CHECK your plan
  • Is it a reaction to something? (beside your heart)
  • What does it solve, contribute?
  • How well does it fit in?
  • Is the plan conditional? (the plan works if .... )
  • What/whohas to cooperate to make it a success?
  • What are the consequences?
c riteria f or a go o d plan
CRITERIA FOR A GOOD PLAN
  • Objectives clearly indicated?
  • Goal and policy transparant?
  • Based on a thorough analysis?
  • Was the literature consulted?
  • Consistent?
  • Realistic?
  • Plan is stimulating or rather frustating?
  • Money and means are explicitly mentioned?
  • Tasks and responsibilities explicit?
  • Delegation gets enough attention?
  • Clear priority of steps?
  • Does the plan give enough direction?
learning points
LEARNING POINTS
  • Write them down
  • retrievable
  • to the point
  • factual, concrete
  • specific
  • detailed
  • exchange them in the group and
  • colleagues at home
management of change

MANAGEMENTofCHANGE

An ultimate abstraction

management of change1

MANAGEMENTofCHANGE

Every change has both a technical and social aspect

Technically rational changes can fail if the social aspects of change are not handled well

Every system is perfectly designed to get the results its gets

management of change deliberate leadership
MANAGEMENTofCHANGE Deliberate leadership
  • Goal setting
  • Communicating
  • Coaching
  • Role modeling
  • Support building
  • Barrier removal, facilitation
management of change vision for office practices
MANAGEMENTofCHANGE VISION for office practices

Encounter level principles

  • Paramount focus on the clinician-patient relationship
  • Individual access to care and information at all times
  • Knowledge based medical care as the standard
  • Individuals control and customize their own care to the extent that each individual desires
  • Minimal waiting for all involved in the care process
  • Seamless communication of information & coor-dination of care based on collaborative relationships
management of change vision for office practices1
MANAGEMENTofCHANGE VISION for office practices

System-level principles

  • Financial management sufficient to ensure unhindered viability
  • Patient, population and practice management based on real-time process, satisfaction finance, outcome, and epidemiological data
  • Individual health linked to broader community health perspective
  • Continual improvement and waste reduction in all processes and services
  • A model working environment
management of change aims for improvement
MANAGEMENTofCHANGEAims for improvement
  • Clear, specific, measurable terms
  • Consider ‘stretch’goals, but be prepared
  • Constancy of purpose matters
  • Focus, not everything at once
management of change staff involvement
MANAGEMENTofCHANGEStaff involvement
  • Motivation is internal to a person
  • Create conditions where people’s internal motivation can flourish
  • Start small, but valuable
  • Start non threatening
  • Flow: time is available for things people enjoy doing
  • Rewards: acknowledgement is valuable, respond to all input
  • Be clear abot constraints upfront
  • Focus on opinion leaders
management of change model f or change

MANAGEMENTof CHANGEModel for change

Feedback

CHANGE

Intentionto

change

Tension for

change

An effective

alternative

Social support Self-efficacy skills Plsek

management of change transforming an organisation
MANAGEMENTof CHANGE Transforming an organisation
  • Establish a sense of urgency
  • Form a powerful guiding coalition
  • Create a vision and communicate that vision
  • Empower others to act on that vision
  • Plan and create short term wins
  • Consolidate and produce more change
  • Institutionalize new approaches
management of change sources for change of ideas
MANAGEMENTofCHANGESources for change of ideas
  • Evidence in the literature
  • Benchmarking and the experience of other organizations
  • Expert opinion
  • Ideas based on sound theory
  • Creative thinking
management of change measurement
MANAGEMENTofCHANGEMeasurement
  • Measurement for improvement instead of judgment
  • Usefulness over perfection
    • Simple, easy data collection in daily work
    • Consider sampling
    • Consider existing data sources
  • Timeliness of feedback is key to learning
  • Long ‘baselines’ are often unnecessary
  • Annotated graph of measures over time
management of change why test
MANAGEMENTofCHANGEWhy test?
  • Increases belief that change will result in improvement
  • See how much improvement can be expected
  • Adapt ideas to local context
  • Evaluate cost and side-effects
  • Minimize resistance; create attraction
management of change model f or change1

MANAGEMENTof CHANGEModel for change

Feedback

CHANGE

Intentionto

change

Urgency for

change

An effective

alternative

Social support Self-efficacy skills Plsek

management of change planning for change
MANAGEMENTofCHANGEPlanning for change
  • How will we convince ourselves and others that there is truly a need for change? (URGENCY)
  • How will we convince ourselves and others that the new way is better? (ALTERNATIVE)
  • What will we do to avoid the feeling of Ï am all alone in making change’? (SUPPORT)
  • How will we and others acquire the skils to make the new way work? (SKILLS)