Having more clinicians with formal management training can only be a good thing, but it won’t be a magic bullet
The fix for morale and efficiency woes plaguing the health system needs to begin with letting clinicians own their jobs, Australian research suggests.
A team from the University of NSW Business School went into 20 public hospitals, conducting interviews with executives, doctors, nurses and allied health workers, to identify what was hindering best-practice medicine in this age of supposed “patient-centred” care.
They identified problems on several fronts, but none more evident than the dead hand of human resources management.
Professor Julie Cogin, deputy dean of the business school and a director of its Australian Graduate School of Management, said it was eye-opening to see well-educated, intelligent, senior clinicians burdened by HR demands and processes that were not designed for a clinical environment.
“We talk about patient-centred care as a philosophy we are trying to build in hospitals everywhere, but the main target is around cost and turnover of patients, and this is what is cascading through at all levels,” Professor Cogin said.
Doctors and nurses in senior roles felt their hands were tied on basic people-management decisions such as hiring staff, with delays up and down the management chain so lengthy that a preferred candidate might have moved on before an approval came through.
“At the moment, only risk is devolved to department heads, so we carry the can for adverse outcomes, but we’re not given any trust to hold the purse strings to manage the department or motivate people,” a physician managing a hospital unit complained in an interview.
Professor Cogin said it made sense to have rigid controls on some aspects of hospital policy such as safety and handwashing practices, but not professional elements, such as hiring and rostering.
“There was literally no discretion for senior people to make decisions. It was a surprise to see it to that degree,” she said.
The UNSW research, detailed in the paper Controlling healthcare professionals: how human resource management influences job attitudes and operational efficiency, sought to establish a baseline for the current state of play.
The good news, however, is clinician-led management appears to be on the way back and more clinicians are taking extra qualifications in management and leadership skills.
“It’s a cyclical evolution,” Dr Sharon Miskell, an executive director of medical services in the NSW health system, told The Medical Republic.
“Antibodies have developed to this bottom-line approach of managing according to budget,” Dr Miskell said.
“Clinicians have been incensed about that model being applied to acute care and hospital management. I think people are starting to think we need to move away from this bottom-line, accountant-led approach.
“Having said that, there’s considerable tension between administration and clinicians, in some facilities more than others. I think it’s a legacy of clinicians not feeling there has been sufficient engagement and heed to patient care that has led to that divide.”
A medical graduate who’s had a 30-year career in health and hospital management and did specific managerial and leadership training along the way, Dr Miskell is pleased to see more clinicians seeking formal training to cope with more responsibility.
“Unless clinicians have those skill sets under their belts, they are really struggling, they’re not able to do these roles, and not likely to put up their hands.”
Where the Royal Australian College of Medical Administrators once had only a handful of women as fellows when Dr Miskell did her management training, she was intrigued to see they were now a majority.
Dr David Heslop, director of the Health Management Studies program at UNSW, has observed some doctors are drawn to managerial training by the example of a skilled mentor.
“One of the factors is observation of mentors who do manage well and (doctors) being encouraged to take on extra training,” he said.
“Most clinicians can reflect on things in the past that have not been well managed. It’s an easy step to see the value.
“There is certainly a desire among clinicians to increase their skills in this area.
“A lot of them just want to understand management better. They express the feeling they didn’t have the skills needed to manage teams well, and they didn’t receive that training in great detail during their formative years in medical school.”
Dr Heslop, who combines academic life with a day per week as a practising GP, says doctors are also attracted to the skill sets and knowledge that go into being a manager, being a leader, and learning about organisational management.
“I also think the medical workforce is becoming more competitive, and having a management qualification sets you apart.”
Some are doing “stand-alone upskilling”, intending to expand their private practices. But most are already working in the hospital and health system and on fellowship programs with RACMA, which accepts only doctors, or the Australasian College of Health Services Management.
A successful clinician-manager brought special qualities that helped lift morale.
“It comes down to credibility and trust,” Dr Heslop said.
“In general, clinicians want to be led by someone they trust. Frequently the decisions that need to be made are thorny or require some element of sacrifice or compromise.
“When a decision comes from someone they trust, who can explain, it might be a bitter pill to swallow, but it is more acceptable. That’s something that has been reflected back to me time and time again, from students and colleagues.”
Professor Arthur Van Deth, a medical doctor and administrator turned academic at Flinders University in South Australia, warned that the fast pace of change in medical technology would soon mean a significant rise in what medical managers needed to know.
“Healthcare management has changed from being something that 10 or 20 years ago you could take on and learn as you went along. It has become so technical and so complex, that you need a high-level qualification to do your job well and to find a job at this level,” he said.
“We are really at the beginning of significant disruptive technologies coming in that are really going to change how healthcare is managed and how consumers approach the health sector.”
The director of international programs at Flinders’ Health Care Management school, Professor Van Deth said subjects in data analytics were now in development to help health-system managers make the most of the rise of “big data” and equip them to apply innovative thinking to their work.
“All that is going to explode in the next five to 10 years,” he said.
“We need to be ahead of the game. Our standard program we’ve been offering for the past 20 years is essentially like an MBA for the health sector – finance management, HR, safety and quality, health economics and health policy – all very useful skills in managing a large group practice or a hospital, but we now see a need to adapt our programs to what lies ahead.
Dr Michael Walsh, CEO of the Cabrini private hospital and healthcare group in Melbourne, said human relations were still a key aspect, and any nurse or doctor who saw themselves moving into a managerial role, particularly one involving multidisciplinary teams, would benefit from management training.
“I believe people with medical training and some clinical experience should make good leaders and managers in the health system if they have proper leadership and management training,” he said. “If they don’t, it’s a raffle.
“Ultimately, health, more than any other industry, is a human-relations industry.
“For a clinician who moves into a management and leadership role, you must establish working relationships with people whose work you have to organise. if you find yourself with a team of 10 doctors, nurses and allied health and you’re not happy with the performance of some of them, these are difficult conversations if you have not had the training.”
Interestingly, Australian know-how in health management is a sought-after export.
Professor Van Deth’s program is being taught in China and Singapore to more than 10 times the number of students doing the course in Adelaide. Dr Heslop’s course at UNSW in Sydney is popular with international students, who make up more than one-third of the cohort.
And the UNSW’s Australian Graduate School of Management will start teaching an MBA in health management at the prestigious Kings College of London, later this year.
However, Professor Cogin said addressing the morale and efficiency problems seen in the Australian system would need a lot more action than sending doctors off to training courses.
“These are symptoms of deeper problems,” she said.
While health systems around the globe were overburdened with ageing populations and the evolution of more expensive treatments, drugs, robotics, and chronic illness, hospital performance was measured by how quickly patients were discharged.
In a psychiatric unit that was part of the UNSW study, healthcare professionals had said they felt the practice looked good on paper, but there was no measure of patients returning to the system because they had not been treated effectively while in hospital.
“We have to change the metrics these hospitals are run by. What gets measured, gets done,” Professor Cogin said.
“We have to change the targets. We are disengaging a huge workforce that we really need. There’s a huge, leaky pipeline of the most talented people leaving healthcare because they are just fed up with the whole system – with the hospitals, the way they’re run, the professional bodies.”
Effective change would require all the various stakeholders – including universities, professional bodies and medical colleges – collaborating to work out new training and managing requirements and ways to encourage talented staff to stay.
“This is the baseline. All stakeholders have skin in the game. Let’s start working on steps to making it better. We are not going to move from A to B – but the training of healthcare managers and leaders is a good first step towards B.”