Professor Graham Dickson (Canada) and
Professor Peter Spurgeon (UK)
To explore:



What partnering for
performance means
What the research says
re having medical
leaders as partners in
health reform: how does
it affect performance?
The need for medical
leaders to become
engaged as partners in
health reform
Working together to get results...
 Health reform is a transition from
where we are at now to where we want
to be that is defined within each
country’s need as dictated by situation,
circumstance and context.

Patient-centred care is the focal point
for many jurisdictions.
 It is multi-level: e.g., micro (unit, or
consultancy-based), macro (hospital or
organization-base) or mega
(national/provincial) in scope.
 Medical leadership is required at all
levels for reform to be effective
 The action or process
of carrying out or
accomplishing an
action, task, or
function
 In the context of this
session, the action,
task or function is
productive health
reform.
 A relationship that is characterized
by mutual cooperation and
responsibility, as for the achievement
of a specified goal.
 The state or condition of being a
partner; participation; association;
joint interest.
 In Law.
 a. the relation subsisting between
partners.
 b. the contract creating this
relation.
 c. the persons joined together as
partners in business
The mutual cooperation
and sharing of
responsibility between
medical doctors and
others (non-medical
administrators, other
professions, public) .
The term physician
engagement is used to
characterize the degree
to which we are
committed, and
successful, in forming
partnerships between
medical doctors and
others.
Professor Peter Spurgeon (Project
Director)
Director, Institute of Cinical
Leadership, Medical School,
University of Warwick



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
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
both in operational and strategic activities
 Increase and strengthen the pool of medical managers
and leaders available to take on senior roles within the
service
www.institute.nhs.uk/m
lcf

Defining the territory of leadership: the power
of frameworks
Australia: RACMA
Canada: LEADS
Application of the Framework will differ according to the career stage of
the doctor and the type of role they fulfil. The following graphics
demonstrate the emphasis that is likely to be given to the domains at
each stage:
Undergraduate
Postgraduate
Post-Specialist Certification
Medical Leadership Competency
Framework
Working with Others
Doctors showing effective leadership by
working with others in teams and networks to
deliver and improve services.
This requires doctors to demonstrate
competence in:
Developing networks: working in partnership
with colleagues, patients, carers, service users
and their representatives within and across
systems 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.
Medical Leadership Competency
Framework
Personal Qualities
Doctors showing effective leadership need to
draw upon their values, strengths and abilities
to deliver high standards of care.
This requires doctors to demonstrate
competence in:
Self awareness: being aware of their own values,
principles, assumptions, and by being able to
learn from experiences
Self management: organising and managing
themselves while taking account of the needs
and priorities of others
Self development: learning through
participating in continuing professional
development and from experience and feedback
Acting with integrity: behaving in an open and
ethical manner
Medical Leadership Competency
Framework
Managing Services
Doctors showing effective leadership are
focused on the success of the organisation(s) in
which they work.
Doctors are required to demonstrate
competence in:
Planning: actively contributing to plans to
achieve service goals
Managing resources: knowing that resources
are available and using their influence to ensure
that resources are used efficiently and safely
Managing people: providing direction, reviewing
performance and motivating others
Managing performance: holding themselves and
others accountable for service outcomes
Medical Leadership Competency
Framework
Improving Services
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 risk to patients associated with
service improvement.
Critically evaluating: being able to think
analytically, conceptually and to identify where
services can be improved.
Encouraging innovation: creating a climate of
continuous service improvement.
Facilitating transformation: actively
contributing to change processes that lead to
improving healthcare.
Medical Leadership Competency
Framework
Setting Direction
Doctors showing effective leadership contribute to
the vision 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: integrating values with
evidence to inform decisions
Evaluating Impact: measuring and evaluating
outcomes, taking corrective action where
necessary and by being held to account for their
decisions.
Leadership Framework
(All staff Groups)
From Competence to Engagement
Competence may be thought of as “can do” but
engagement requires “will do”- the motivational
aspect.
Engaged employees characterised by
- belief and pride in their organisation
- commitment to improve the outcome/ product
- understanding of the wider organisational context beyond
their own job role
- respect for colleagues
- “willingness to go the extra mile”
Not
- as process of consultation
- as act “to do”
Rather
- Intra individual notion
- Reservoir of motivation
- Willingness to get involved
UK wide levels of engagement, across sectors said to be
relatively low.
Approx 1/3 workforces truly engaged
Hence any increase in the 1/3 increases organisation capacity,
and therefore performance
From Competence to Engagement cont’d.
So engagement is reciprocally beneficial
a) Organisation- performance, customer
satisfaction, reduced absenteeism, turnover
b) Individual- improved job satisfaction, lower
burnout rate
Definition of engagement built into MES is therefore
“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 and Mazelan 2008)




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 and complete
MES Reliability & Validity


Overall items reduced to 30 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 construct
b) 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 independently as excellent & have taken steps to
promote medical engagement, the last is in the
poorest performing category & the opportunistic site is
in the middle
MES Scale
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]
...all staff are friendly towards doctors and are sympathetic to their workload and
work priorities.
Good Interpersonal Relationships
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]
...doctors consider that they are able to make a positive impact through decisionmaking about future developments
Participation in Decision-Making and Change
Sub Scale 5: [O] Development Orientation
...doctors feel that they are encouraged to develop their skills and progress their
career
Sub Scale 6: [I]
...doctors feel satisfied with their working conditions and feel a real sense of
attachment and reward from belonging to the organisation
Commitment & Work Satisfaction
Many Organisational
Opportunities
Doctors feel
CHALLENGED
Doctors feel
ENGAGED
Trust D
Trust A
Restricted
Individual
Capacities
Trust B
Expanded
Individual
Capacities
Trust C
Doctors feel
POWERLESS
Doctors feel
FRUSTRATED
Few Organisational
Opportunities
Meta-Scales: Position on
Model for 4 Pilot Trusts
Many Organisational
Opportunities
Many Organisational
Opportunities
Doctors feel
CHALLENGED
Doctors feel
ENGAGED
Doctors feel
CHALLENGED
Many Organisational
Opportunities
Doctors feel
ENGAGED
Doctors feel
CHALLENGED
Trust D
Doctors feel
ENGAGED
Trust B
Trust D
Trust A
Trust C
Trust B
Trust D
Trust A
Trust C
Restricted
Individual
Capacities
Expanded
Individual
Capacities
Trust A
Trust B
Trust C
Doctors feel
POWERLESS
Doctors feel
FRUSTRATED
Few Organisational
Opportunities
Meta-Scale 1:
Working in an open
culture
Doctors feel
POWERLESS
Doctors feel
FRUSTRATED
Few Organisational
Opportunities
Meta-Scale 2:
Having Purpose &
Direction
Doctors feel
POWERLESS
Doctors feel
FRUSTRATED
Few Organisational
Opportunities
Meta-Scale 3:
Feeling Valued &
Empowered
1
6
Embedded
Doctors are fully involved at all levels in
leading the design and delivery of service
innovations
Expanded
Doctors traditional roles have become
expanded to embrace some aspects of
managing healthcare
Energised
Doctors are keen to become more
involved in the planning, design and
delivery of services
Expectant
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 role
Excluded
Levels of Medical Engagement
Summary for Trust 28
KEY
Medical Engagement Scales:
High Relative Engagement (Top 1/3rd Trusts)
Medium Relative Engagement (Middle 1/3rd Trusts)
Low Relative Engagement (Bottom 1/3rd Trusts)
Relative Normative Feedback
Trust 28
Professional
Engagement
MEDIUM
Climate for
Positive
Learning
LOW
Working in
an Open &
Fair Culture
Having
Purpose &
Direction
Being Valued
& Empowered
MEDIUM
LOW
HIGH
Good
Interpersonal
Relationships
HIGH
Appraisal &
Rewards
Effectively
Aligned
MEDIUM
Development
Orientation
Participation
in DM &
Change
LOW
HIGH
O
Commitment
& Work
Satisfaction
MEDIUM
I
Levels of Medical Engagement for All
Trusts in Current Sample
Engagement
Meta Scale 1
Meta Scale 2
Trust 1
6
10
4
Trust 2
15
24
13
Trust 3
26
23
26
Trust 4
22
20
22
Trust 5
4
4
Trust 6
11
Trust 7
12
Trust 8
Meta Scale 3
Sub Scale 1
Sub Scale 2
Sub Scale 3
Sub Scale 4
Sub Scale 5
7
4
11
23
26
14
5
4
5
17
9
18
27
26
Trust 9
19
Trust 10
Trust 11
Sub Scale 6
23
7
3
11
7
21
20
8
12
10
20
22
26
23
26
25
22
14
23
12
16
13
6
5
5
6
5
4
19
7
4
14
21
13
19
15
13
6
13
25
9
23
28
28
26
26
29
26.5
28
28
22
10
23
15
27
10
10
27
17
7
6
6
10
5
12
15
1
22
6
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
2
CQC Ratings Against Top/Bottom MES
Scores
The table below illustrates the quantitative data in more concrete terms by showing the difference
in performance level achieved on Care Quality Commission ratings by those Trusts in the top 10
and bottom 10 on the MES.
Overall
Medical
Trust ID
Engagement
.
Scale
(Trust nam es
Index
w ithheld for
.
confidentiality)
(in descending
order)
CQC - NHS performance ratings 2008/09
Overall
quality
score
Core
Existing
National
Financial
standards commitment
priorities
management score (as a s score (as a score (as a
score
provider of provider of provider of
services)
services)
services)
21
65.8
Good
Excellent
Fully Met
Fully Met
Good
12
65.2
Good
Good
Fully Met
-
Good
15
63.4
Excellent
Good
Fully Met
Fully Met
Excellent
5
62.0
Excellent
Excellent
Fully Met
Fully Met
Excellent
24
60.8
Good
Excellent
Fully Met
-
Good
1
60.4
Excellent
Excellent
Fully Met
Fully Met
Excellent
10
59.9
Good
Excellent
Almost Met
Fully Met
Good
16
59.8
Good
Fair
Fully Met
Almost Met
Excellent
14
59.7
Excellent
Excellent
Fully Met
Fully Met
Excellent
11
58.8
Excellent
Excellent
Fully Met
Fully Met
Excellent
25
56.8
Fair
Fair
Almost Met
Fully Met
Poor
4
56.7
Fair
Fair
Almost Met
Fully Met
Fair
22
55.7
Fair
Fair
Partly Met
Almost Met
Good
.
(Trust nam es
w ithheld for
confidentiality)
Scale
Index
.
Overall
quality
score
Core
Existing
National
Financial
standards commitment priorities
management score (as a s score (as a score (as a
score
provider of provider of provider of
services)
services)
services)
CQC Ratings Against Top/Bottom MES
Scores
(in descending
order)
21
65.8
Good
Excellent
Fully Met
Fully Met
Good
12
65.2
Good
Good
Fully Met
-
Good
15
63.4
Excellent
Good
Fully Met
Fully Met
Excellent
5
62.0
Excellent
Excellent
Fully Met
Fully Met
Excellent
24
60.8
Good
Excellent
Fully Met
-
Good
1
Overall
60.4
Medical
Engagement
59.9
Scale
Index
59.8
.
Excellent
Excellent
Fully Met
Fully Met
Excellent
Good
Excellent
Almost Met
Fully Met
Overall
Good
quality
score
Excellent
Trust ID
10
.
(Trust nam es
16 for
w ithheld
confidentiality)
CQC - NHS performance ratings 2008/09
Good
Financial
Fair
management
score
Excellent
Core
standards
Fully Met
score (as a
provider
Fully Metof
services)
Existing
commitment
Almost Met
s score (as a
provider
Fully Metof
services)
National
priorities
Excellent
score (as a
provider
Excellentof
services)
14
(in descending
59.7
order)
11
58.8
Excellent
Excellent
Fully Met
Fully Met
Excellent
21
25
65.8
56.8
Good
Fair
Excellent
Fair
Fully Met
Almost
Met
Fully Met
Good
Poor
12
4
65.2
56.7
Good
Fair
Good
Fair
Fully Met
Almost
Met
Fully- Met
Good
15
63.4
Excellent
Good
Fully Met
Fully Met
Excellent
22
55.7
62.0
Excellent
Excellent
Fair
Partly Met
Almost Met
Fully Met
Excellent
23
24
55.3
60.8
Fair
Good
Good
Excellent
Almost
Met
Fully Met
Partly- Met
Excellent
Good
1
29
60.4
54.4
Excellent
Good
Excellent
Fully Met
Fully Met
Excellent
Good
10
3
59.9
54.3
Good
Fair
Excellent
Excellent
Almost Met
Fully Met
Fully Met
Fully
Met
Good
16
59.8
Good
Fair
Fully Met
Almost Met
Excellent
5
Fair
Fair
Good
Poor
26
53.1
59.7
Excellent
Excellent
Fair
Almost Met
Almost Met
Fully Met
Excellent
8
11
52.7
58.8
Good
Excellent
Good
Excellent
Fully
Fully Met
Met
Almost
Met
Fully Met
Good
Excellent
25
18
56.8
52.1
Fair
Fair
Almost
Met
Fully Met
Fully Met
Partly
Met
Poor
Good
4
20
56.7
47.0
Fair
Poor
Fair
Poor
Almost Met
Almost
Met
Fully Met
Fair
Fair
22
55.7
Fair
Fair
Partly Met
Almost Met
Good
23
55.3
Fair
Good
Almost Met
Partly Met
Excellent
29
54.4
Good
Excellent
Fully Met
Fully Met
Good
3
54.3
Fair
Excellent
Fully Met
Fully Met
Poor
26
53.1
Fair
Fair
Almost Met
Almost Met
Fair
8
52.7
Good
Good
Fully Met
Almost Met
Good
18
52.1
Fair
Fair
Fully Met
Partly Met
Good
14
Fair
Fully Met
Fully Met
Not Met
Fair
MES Scales
MES Scales
Examples of CQC Indicators
Patient Survey
Key Indicators
Index of Medical Engagement
Meta 1 - Working in a Collaborative Culture
Meta 2 - Having Purpose & Direction
Meta 3 - Being Valued and Empowered
Sub 1 - Climate for Positive Learning
Sub 2 - Good Interpersonal Relationships
Sub 3 - Appraisal and Rewards Effectively Aligned
Sub 4 - Participation in Decision-Making & Change
Sub 5 - Development Orientation
Sub 6 - Work Satisfaction
IPSurfConfDoc IPSurfInvDeci SINAP15 NHFD01
0.67
0.59
0.60
0.62
0.55
0.69
0.57
0.58
0.59
0.55
0.66
0.66
0.64
0.62
0.72
0.61
0.64
0.62
KEY:
IPSurConfDoc = Inpatient Survey 2012 Q25 "Did you have confidence and trust in the doctors treating you?"
IPSurInvDeci = Inpatient Survey 2012 Q32 "Were you involved as much as you wanted to be in decisions about your care and treatment?"
SINAP15 = Key Indicator 8: Number of potentially eligible patients thrombolysed
NHFD01 = National Hip Fracture Database: measure of cases assessed as achieving compliance with all nine Best Practice Tariff standards of care
Benefits of Engagement (U.K.)
 Better patient mortality rates
 Fewer serious untoward accidents
 Better financial management
 Higher patient experience scores
 Better resource utilisation
 Achievement of service targets
USA hospitals with more engagement have better service
performance and financial stability
Engagement has significant currency in private sector
“Engage for Success” national focus
U.K. levels of engagement quite low across all sectors
Medical Engagement and Organisational Performance
What can we learn from trusts with high levels of medical engagement?
• Leadership, stable, relationship oriented, leading by example
• A future-focused and outward-looking culture
• Attention to selection and appointment of the right doctors to leadership
and management
• Providing support, development and leadership opportunities
• Effective communication
• Promotion of understanding, trust and respect between doctors and
managers
• Setting expectations, enforcing professional behaviour and firm decisionmaking
• Clarity of roles and responsibilities and empowerment
Percentage of Respondents (n = 399) who fell
into High, Medium and Low Normative Bands
High
Medium
Low
Medical Engagement Index
20.5%
9.8%
69.7%
Meta-Scale 1: Working in a Collaborative Culture
21.0%
18.3%
65.4%
Meta-Scale 2: Having Purpose and Direction
14.8%
10.0%
79.7%
Meta-Scale 3: Feeling Valued & Empowered
22.1%
8.3%
69.7%

Directions:

Prepare to report out.
◦ At your table, discuss what
health reform challenges—
from a patient-centred focus-you are facing in your own
area of responsibility.
◦ To what extent are doctors
truly engaged as it relates to
health reform in your country?
◦ Would the MES engagement
scale be useful to you in
improving engagement?
Thank you
Peter Spuregon,
P.C.Spurgeon@warwick.ac.uk
 Graham Dickson,
gdickson@royalroads.ca
