Medical Engagement Scale

Transcription

1 Engage to Perform Ltd Medical Engagement Scale Cardiff & Vale UHB July 2016

2 The Medical Engagement Scale (MES) Engagement of Medical Staff in Cardiff & Vale UHB ' (July 2016) CONTENTS PREFACE: MEDICAL ENGAGEMENT IN WALES Overview Summary 1) INTRODUCTION a) What is Medical Engagement? b) Hierarchical Structure of the MES Instrument c) Complementary Approaches to Interpreting MES Norms 2) SURVEY RESULTS a) Composition of the Cardiff & Vale UHB Sample b) Average Levels of Medical Engagement Levels of Medical Engagement for Staff Groups Levels of Medical Engagement for Clinical Boards/Directorates Levels of Medical Engagement for Specialties Levels of Medical Engagement & Types of Contract Levels of Medical Engagement & Managerial Responsibility c) Distribution Profiles of Medical Engagement d) Alignment of Medical Ratings and Managerial Perceptions 3) LOCAL QUESTIONS 4) OPEN ITEMS 5) SUGGESTED INTERVENTIONS 6) THE WELSH PERSPECTIVE 7) CHANGES IN MEDICAL ENGAGEMENT OVER TIME 1

3 PREFACE: MEDICAL ENGAGEMENT IN WALES This year (2016) is the first year in which linked medical engagement surveys have been systematically undertaken by the following group of eight NHS organisations in Wales which are listed below: ABMU UHB Aneurin Bevan UHB Betsi Cadwaladr UHB Cardiff & Vale UHB Cwm Taf UHB Hywel Dda UHB Velindre Trust Public Health Wales The initial aim of this Pan-Wales medical engagement survey is to provide a reliable and valid baseline of Welsh doctors perceptions about the opportunities and interests they have in adopting expanded medical roles particularly with respect to the planning, design and delivery of improved patient services. Each of the participating healthcare organisations in Wales have used a common MES survey structure and this ensures that the results are not only comparable between organisations but also enables the construction of Welsh medical engagement norms which will facilitate reliable benchmarking of progress in future years. Although the advantages of using a common core of engagement items are clear, it is also important that each of the eight survey questionnaires are tailored to incorporate local issues selected as relevant by the participating organisations themselves. By combining common and local items within each of the survey instruments, medical engagement issues may be simultaneously viewed from both a national Welsh and a topical local perspective. - A Note about the MES Reports The current 2016 assessment of medical staff engagement within the eight Welsh health organisations listed above is being undertaken concurrently, although there will inevitably be variations between organisations with respect to the time spent in the local organisation and administration of each of their MES surveys and, more importantly, securing sufficient medical returns in the data collection phase. Consequently, as survey data becomes available for each organisation it will be analysed in turn and an engagement report for each organisation will be produced. This report (for the Cardiff & Vale UHB ) is intended to be a focused feedback document that has been designed to give an overview of the levels and types of medical engagement which have been identified within the organisation together with some brief recommendations of potential methods for enhancing medical engagement if and where the results have identified scope for improvement. In addition to producing the eight separate medical engagement reports for each participating organisation, the final report will present a more integrated and focussed assessment of medical engagement in Wales, based on constructing a database of Welsh medical norms from the MES survey results and using this to statistically benchmark levels of engagement against the new Pan-Wales normative database. 2

4 The Medical Engagement Scale (MES) Overview Summary for Cardiff & Vale UHB' Overview Summary In all, 362 members of medical staff completed the MES survey at the Cardiff & Vale UHB. A comparison of the current survey results with the other Trusts in the main normative database (comprising over 100 Trusts and more than 12,500 medical staff - i.e. Consultant, Associate Specialist/Staff Grade and trainees) indicated the following: - For the average of all responding medical staff, eight of the ten MES scales were rated within the low relative engagement band compared to the external norms. One MES scale (i.e. Sub-Scale 5: Development Orientation) was rated within the lowest relative engagement band and the one remaining MES scale (i.e. Sub-Scale 1: Climate for Positive Learning) was rated within the medium relative engagement band compared to the external norms. Consultants (n = 289) and Associate Specialists (n = 9) were both predominantly disengaged. Consultants rated two MES scales (i.e. Sub-Scale 2: Good Interpersonal Relationships and Sub-Scale 5: Development Orientation) within the lowest relative engagement band. Associate Specialists also rated Sub-Scale 5: Development Orientation) within the lowest relative engagement band. Staff groups Specialty Grade Doctor/Staff Grade (n = 17), GP/Dental (n = 15) and Other (n = 26) were associated with a more mixed engagement profile. Specifically, staff group GP/Dental (n = 15) rated three MES scales within the high relative engagement band and staff group Specialty Grade Doctor/Staff Grade rated five MES scales within the high band and three MES scales within the highest relative engagement band compared to the external norms. A comparison of levels of engagement between those members of medical staff with a Honorary/University contract (n = 44) compared to those medical staff with a UHB contract (n = 315) revealed that that those members of medical staff with a Honorary/University contract were consistently more engaged with respect to all of the ten MES scales compared to their colleagues with a UHB contract. Medical staff with a position of managerial responsibility (n = 87) were more engaged with respect to all ten MES scales compared to their colleagues without a position of managerial responsibility. Two MES scales highlighted the key areas that most strongly characterise the engagement profiles of those members of medical staff who take on positions of managerial responsibility. These were Meta-Scale 3: Feeling Valued and Empowered and its constituent Sub-Scale 6: Work Satisfaction. Overall, senior managers estimates of medical engagement well aligned to medical staff ratings suggesting a realistic managerial understanding of the demands placed on medical staff at Cardiff & Vale UHB. The medical staff ratings of the local items provided a mixed picture of working in Cardiff & Vale UHB. For example whereas 54% that they have regular involvement with the leadership team within their own specialties but only 28% endorsed the statement that The working arrangements in this organisation facilitate my opportunities to discuss quality, safety and performance with Senior Managers, including the Chief Executive (formally or informally). 3

5 1) INTRODUCTION a) What is Medical Engagement It is increasingly recognised that improvement in healthcare needs the positive involvement and engagement of doctors who are willing and able to adopt roles that make them highly influential in planning and delivering service change. Although competence may be thought of as what doctors can do, medical engagement requires a will do attitude. The reliable and valid measurement and monitoring of medical engagement is critical since this will inform and shape effective improvement initiatives. Although, many definitions of engagement focus solely on individual and personal aspects the current approach also incorporates organisational conditions and culture. Our definition of Medical Engagement is: - 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. b) Hierarchical Structure of the MES Instrument The Medical Engagement Scale (MES) is a simple and short 30-item survey instrument consisting of ten reliable and valid scales. The instrument has a hierarchical structure and provides an overall index of medical engagement together with an engagement score on three reliable meta-scales with each of these three meta-scales itself comprising two reliable sub-scales: Meta-Scale 1: Working in a collaborative culture Sub-Scale 1: Climate for positive learning Sub-Scale 2: Good interpersonal relationships MEDICAL ENGAGEMENT Meta-Scale 2: Having purpose and direction Sub-Scale 3: Appraisal and rewards effectively aligned Sub-Scale 4: Participation in decisionmaking and change subscales metascales Meta-Scale 3: Feeling valued and empowered Sub-Scale 5: Development orientation Sub-Scale 6: Work satisfaction RECIPROCATE (Collaboration) GIVE (Committment) RECEIVE (Satisfaction) Furthermore, the structure of the MES comprises two types of engagement sub- scale: - 4

6 Three ORGANISATIONAL Sub-Scales (1, 3 and 5) which reflect the cultural conditions which facilitate or inhibit medical staff to be more actively involved in leadership and management Three INDIVIDUAL Sub-Scales (2, 4 and 6) which reflect medical empowerment and confidence to tackle new management and leadership challenges ORGANISATIONAL INDIVIDUAL Sub-Scale 5 Sub-Scale 6 RECEIVE Satisfaction "Development Orientation" Meta-Scale 3 "Being Valued & Empowered" "Work Satisfaction" Sub-Scale 3 Sub-Scale 4 GIVE Commitment "Appraisal & Rewards Effectively Aligned" Meta-Scale 2 "Having Purpose & Direction" "Participation in Decision Making & Change" Sub-Scale 1 Sub-Scale 2 RECIPROCATE Collaboration "Climate for Positive Learning" Meta-Scale 1 "Working in a Collaborative Culture" "Good Interpersonal Relations" MEDICAL ENGAGEMENT Brief definitions of each of the MES scales are shown in the table below. 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 a Collaborative 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] Good Interpersonal Relationships...all staff are friendly towards doctors and are sympathetic to their workload and work priorities. 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] Participation in Decision-Making and Change...doctors consider that they are able to make a positive impact through decisionmaking about future developments Sub Scale 5: [O] Development Orientation...doctors feel that they are encouraged to develop their skills and progress their career Sub Scale 6: [I] Work Satisfaction...doctors feel satisfied with their working conditions and feel a real sense of attachment and commitment to the organisation 5

7 Complementary Approaches to Interpreting MES NORMS To date, MES surveys have been undertaken in over 100 participating hospital Trusts and these have been used to establish a large, valid normative database consisting of the collated engagement ratings from over 12,500 members of medical staff. This main normative database provides a growing set of valid reference scale scores against which to benchmark the medical engagement profiles of all grades of doctor who work in healthcare organisations. The purpose of this report is to provide feedback about the relative levels of medical staff engagement at Cardiff & Vale UHB based on statistical comparisons with the norms and to discuss the implications of these results with respect to helping identify the priority for potential managerial interventions. There are two broad ways in which to consider the meaning of MES scale scores. For any particular staff sample or sub-sample in question, the first approach is based on calculating the mean (i.e. the average) scores for each of the ten MES scales and to compare the level of these averages scores with the external normative database. The second approach is based on comparing the frequency distribution of scores rather than comparing averages. This second approach involves comparing the expected number of doctors who fell into different levels of engagement bands with the number of doctors actually observed within those bands at a particular site. In other words, this second method compares expected frequencies (i.e. derived from the norms) with observed frequencies (i.e. derived from the survey scores). Both methods are helpful in understanding the MES scale scores and their interpretation. 6

8 2) SURVEY RESULTS a) Composition of the Cardiff & Vale UHB Medical Sample In all 362 members of medical staff participated in the current MES survey and the two pie charts shown below detail the percentage breakdown of MES survey respondents by: a) Staff Groups b) Clinical Board/Directorates a. b. Consultant, 289, 81% Not specified, 1, 0% Children & Women, 50, 14% Clinical Diagnostics & Therapeutics, 41, 11% Surgical Services, 58, 16% Dental, 50, 14% Not specified, 1, 0% Other, 26, 7% Trainee Grade, 4, 1% GP/Dentist, 15, 4% Fellow, 1, 0% Specialty Grade Doctor / Staff Grade, 17, 5% Associate Specialist, 9, 2% Specialist Services, 61, 17% Primary, Community Intermediate Care, 13, 4% Mental Health, 28, 8% Medicine, 60, 16% The table below details the frequency and percentage composition of respondents by Specialty. Specialty Frequency Percentage Accident and Emergency/Acute Medicine Anaesthetics (including ITU & Critical Care) Cardiac Services Clinical & Medical Genetics Dental Health {Community/Hospital) Diabetes & Endocrinology ENT Elderly Care Medicine/Gerontology Gastroenterology General Medicine General Surgery Community (incl. Frailty, Pallitive Care,Salaried GP's, GP O Haematology & Clinical Immunology Laboratory Medicine & Toxicology Laboratory Mental Health (incl Adult, Old Age, Psychiatry & LD) Nephrology & Transplant Neurosciences Obstetrics and Gynaecology Ophthalmology Paediatrics (incl Acute Child Health Services) Radiology (incl Imaging, Clinical) Trauma and Orthopaedics

9 The table shows that some specialties only had a low number of respondents and this precluded any further analysis since this might prove statistically unreliable or could compromise the anonymity of medical staff respondents. b) Average Levels of Medical Engagement The average medical engagement scores for all Trusts in the external normative database (currently over 100 and growing) were ranked and split into five main engagement bands for each of the ten MES scales. These bands are defined in the table below and can range from high relative engagement (coloured green) to low relative engagement (coloured red). Based on all members of medical staff who completed the current MES survey (n = 362), the coloured hierarchical figure and the table below shows where this particular Trust fell with respect to the normative database. The hierarchical MES figure shows that for the average of all responding medical staff, eight of the ten MES scales were rated within the low relative engagement band compared to the external norms (coloured pink in the hierarchy). One MES scale (i.e. Sub-Scale 5: Development Orientation) was rated within the lowest relative engagement band (coloured red in the hierarchy) and the one remaining MES scale (i.e. Sub-Scale 1: Climate for Positive Learning) was rated within the medium relative engagement band (coloured yellow in the hierarchy). This variation across the scales is generally indicative of different levels of medical staff engagement, but it must be remembered that these results represent data aggregated across a number of organisational categories and consequently many of the underlying variations in engagement level would tend to flatten out and not be apparent in these 8

10 averaged results. Therefore, in order to examine the levels and pattern of medical engagement in greater detail, these overall results were disaggregated in several ways as shown below. - By Staff Group - By Clinical Board/Directorate - By Specialty - By Type of Contract - By Managerial Responsibility Levels of Medical Engagement for Staff Groups Whole Sample Consultant Specialty Grade Doctor / Staff Grade Associate Specialist GP/Dentist Other Index of Medical Engagement Meta Scale 1 Working in a Collaborative Culture Meta Scale 2 Having Purpose & Direction Meta Scale 3 Being Valued & Empowered Sub Scale 1 Climate for Positive Learning Sub Scale 2 Good Interpersonal Relationships Sub Scale 3 Appraisal and Rewards Effectively Aligned Sub Scale 4 Participation in Decision-Making & Change Sub Scale 5 Development Orientation Sub Scale 6 Work Satisfaction n An inspection of the table above shows that, compared to the norms, two medical staff groups (i.e. Consultant, n = 289, and Associate Specialist, n = 9) were both predominantly disengaged. Consultants rated and the remaining two MES scales (i.e. Sub-Scale 2: Good Interpersonal Relationships and Sub-Scale 5: Development Orientation) within the lowest relative engagement band. Associate Specialists also rated Sub-Scale 5: Development Orientation) within the lowest relative engagement band and rated eight of the ten MES scales within the low relative engagement band. 9

11 In contrast, the other Staff Groups - i.e. Specialty Grade Doctor/Staff Grade (n = 17), GP/Dental (n = 15) and Other (n = 26) - were all associated with a more mixed engagement profile. All three staff groups had rated some MES scales in line with the high or highest levels of medical engagement compared to the external norms. Specifically, staff group GP/Dental (n = 15) rated three MES scales within the high relative engagement band and staff group Specialty Grade Doctor/Staff Grade rated five MES scales within the high band and rated three MES scales within the highest relative engagement band. Levels of Medical Engagement for Clinical Boards/Directorate I In order to examine the levels and pattern of medical engagement within the Clinical Boards/Directorates in greater detail, the table shown below presents the levels of medical engagement disaggregated by these eight categories. Children & Women Clinical Diagnostics & Therapeutics Dental Medicine Mental Health Primary, Community Intermediate Care Specialist Services Surgical Services Index of Medical Engagement Meta Scale 1 Working in a Collaborative Culture Meta Scale 2 Having Purpose & Direction Meta Scale 3 Being Valued & Empowered Sub Scale 1 Climate for Positive Learning Sub Scale 2 Good Interpersonal Relationships Sub Scale 3 Appraisal and Rewards Effectively Aligned Sub Scale 4 Participation in Decision-Making & Change Sub Scale 5 Development Orientation Sub Scale 6 Work Satisfaction n It is apparent from the above table that when the aggregated medical engagement results are broken down to the finer-grain level, the engagement profiles of some Clinical Boards/Directorates generally indicated predominantly low levels of medical engagement. 10

12 Clearly, members of medical staff in affiliated to six Hospital/Sites were, on average, predominantly disengaged across most of the MES scales:- Clinical Diagnostics & Therapeutics lowest engagement band on 10 MES scales (n = 41) Surgical Services (n = 58) Medicine (n = 60) Specialist Services (n = 61) lowest engagement band on 9 MES scales low engagement band on 1 MES scale lowest engagement band on 3 MES scales low engagement band on 7 MES scale lowest engagement band on 2 MES scales low engagement band on 7 MES scales On the other hand, two other Clinical Boards/Directorates are predominantly associated with medium levels of medical engagement. Children & Women (n = 50) Mental Health (n = 28) medium engagement band on 7 MES scales medium engagement band on 6 MES scales In contrast, two other Directorates are predominantly associated with high levels of medical engagement. Dental (n = 50) Primary, Community Intermediate Care (n = 13) highest engagement band on 7 MES scales high engagement band on 2 MES scales highest engagement band on 3 MES scales high engagement band on 5 MES scales Levels of Medical Engagement for Specialties In order to examine the levels and pattern of medical engagement within the Specialties in greater detail, the table shown overleaf presents the levels of medical engagement disaggregated by these nineteen categories. 11

13 Accident and Emergency/Acute Medicine Anaesthetics (including ITU & Critical Care) Cardiac Services Clinical & Medical Genetics Dental Health {Community/Hospital) Diabetes & Endocrinology Elderly Care Medicine/Gerontology Gastroenterology General Medicine General Surgery Community (incl. Frailty, Pallitive Care,Salaried GP Haematology & Clinical Immunology Laboratory Medicine & Toxicology Laboratory Mental Health (incl Adult, Old Age, Psychiatry & LD) Nephrology & Transplant Neurosciences Obstetrics and Gynaecology Paediatrics (incl Acute Child Health Services) Radiology (incl Imaging, Clinical) Index of Medical Engagement Meta Scale 1 Working in a Collaborative Culture Meta Scale 2 Having Purpose & Direction Meta Scale 3 Being Valued & Empowered Sub Scale 1 Climate for Positive Learning Sub Scale 2 Good Interpersonal Relationships Sub Scale 3 Appraisal and Rewards Effectively Aligned Sub Scale 4 Participation in Decision-Making & Change Sub Scale 5 Development Orientation Sub Scale 6 Work Satisfaction n

14 It is apparent from the above table that when the aggregated medical engagement results are broken down to the finer-grain level, the engagement profiles of some Specialities are predominantly characterised low levels of medical engagement. Anaesthetics (n = 44) Radiology (n = 21) Neurosciences (n = 19) lowest engagement band on 10 MES scales lowest engagement band on 10 MES scales lowest engagement band on 6 MES scales low engagement band on 4 MES scales Laboratory Medicine & Toxicology lowest engagement band on 6 MES scales (n = 18) low engagement band on 1 MES scale Accident & Emergency/Acute Medicine lowest engagement band on 1 MES scale (n = 10) low engagement band on 9 MES scales General Surgery (n = 13) Nephrology & Transplant (n = 13) Obstetrics & Gynaecology (n = 10) low engagement band on 10 MES scales low engagement band on 6 MES scales low engagement band on 6 MES scales Members of medical staff affiliated to eight Specialities were, on average, predominantly associated with a medium level of engagement. Haematology & Clinical Immunology (8) Clinical & Medical Genetics (n = 7) Gastroenterology (n = 6) Diabetes & Endocrinology (n = 7) Mental Health (n = 26) Cardiac Services (n = 11) Paediatrics (n = 40) Community (n = 11) medium engagement band on 10 MES scales medium engagement band on 10 MES scales medium engagement band on 10 MES scales medium engagement band on 8 MES scales medium engagement band on 7 MES scales medium engagement band on 7 MES scales medium engagement band on 6 MES scales medium engagement band on 5 MES scales In contrast, three remaining Specialties were predominantly associated with high levels of medical engagement. Dental Health (n = 49) General Medicine (n = 29) Elderly Care Medicine/Gerontology (11) highest engagement band on 8 MES scales high engagement band on 2 MES scales high engagement band on 8 MES scales high engagement band on 6 MES scales 13

15 The underlying reasons for these various Speciality medical engagement profiles are not evident from inspecting the MES results in isolation from an understanding of on-theground medical working conditions. Further probing at the local level should uncover the causes and consequences of identified low levels of engagement and point to ways in which these situations may be improved. Levels of Medical Engagement and Type of Contract A comparison of levels of engagement between those members of medical staff with a Honorary/University contract (n = 44) compared to those medical staff with a UHB contract (n = 315) is shown in the table below. Honourary Contract / University UHB Index of Medical Engagement Meta Scale 1 Working in a Collaborative Culture Meta Scale 2 Having Purpose & Direction Meta Scale 3 Being Valued & Empowered Sub Scale 1 Climate for Positive Learning Sub Scale 2 Good Interpersonal Relationships Sub Scale 3 Appraisal and Rewards Effectively Aligned Sub Scale 4 Participation in Decision-Making & Change Sub Scale 5 Development Orientation Sub Scale 6 Work Satisfaction n An examination of the table above shows that those members of medical staff with a Honorary/University contract were more engaged with respect to all of the ten MES scales compared to their colleagues with a UHB contract. 14

16 Levels of Medical Engagement and Managerial Responsibility WITH a position of managerial responsibility NO position of managerial responsibility Index of Medical Engagement Meta Scale 1 Working in a Collaborative Culture Meta Scale 2 Having Purpose & Direction Meta Scale 3 Being Valued & Empowered Sub Scale 1 Climate for Positive Learning Sub Scale 2 Good Interpersonal Relationships Sub Scale 3 Appraisal and Rewards Effectively Aligned Sub Scale 4 Participation in Decision-Making & Change Sub Scale 5 Development Orientation Sub Scale 6 Work Satisfaction n An examination of the table above shows that those members of medical staff with a position of managerial responsibility (n = 87) were more engaged with respect to all ten MES scales compared to their colleagues without a position of managerial responsibility. Both groups of medical staff rated one scale (i.e. Sub-Scale 3: Appraisal & Rewards Effectively Aligned) within the medium relative engagement band compared to the norms. Three MES scales were characterised by the highest rating band for members of medical staff with a position of managerial responsibility and the lowest rating band for members of medical staff without a position of managerial responsibility. These scales were: - - Index of Medical Engagement - Meta-Scale 3: Feeling Valued and Empowered - Sub-Scale 6: Work Satisfaction These contrasting MES scales highlight the key areas that most strongly characterise the engagement profiles of those members of medical staff who take on positions of managerial responsibility. Whether enhanced engagement is a cause or a consequence of assuming these expanded roles, it does suggest that these areas are critical in developing and sustaining high levels of medical engagement in Cardiff & Vale UHB. 15

17 c) Distribution Profiles of Medical Engagement We have seen in Section b) above that average scores can provide a useful summary of how all members of medical staff who participated in the engagement survey have rated all of the MES scales compared to the norms. Of course, averages only tell part of the story since similar averages may conceal very different underlying distributions of scores. Knowing the shape of these distributions is sometimes important in identifying the proportion of medical respondents who may be either strongly or weakly engaged with service design and delivery. In other words, it may be useful to identify clusters of medical staff that are associated with relatively high or relatively low levels of engagement. For each of the ten medical engagement scales in turn, the distribution of scores for all medical staff in the normative database (i.e. currently over 12,500 medical staff) were split into five bands of scores (labelled A to E) - the upper and lower limits of each band being adjusted so that 20% of doctors in the norms fell into each one. A set of histograms detailing the expected and observed frequency of members of medical staff affiliated to Cardiff & Vale UHB is shown overleaf. The interpretation of these histograms centres on examining the percentage deviation of the observed frequency distributions of the doctors' ratings (above or below) from the expected 20% norm line. If any of the doctors' histogram bars (i.e. A to E) fall above the 20% norm line, then they are rating above the level that we would expect from the external thresholds. Conversely, if any of the histogram bars (i.e. A to E) falls below the 20% norm line then this shows that there are a fewer number of doctors rating at this level than we would expect from the normative bandwidths. For this particular Trust, the ten histograms (shown overleaf) highlight the percentage of doctors who fell into each of these five bands of scores and this enables a comparison to be made between the profiles of medical engagement scores within this Trust compared to the group norm. Clearly, organisational efforts to enhance medical engagement should focus on areas where there are more relatively disengaged groups of medical staff. 16

18 Medical Engagement Index More than Norm Cardiff & Vale UHB: [Sample n = 362] Relative Levels of Medical Engagement [Percentage of Medical Staff in 5 Bandwidths A - E] NORM Level of Engagement [20%] 15.5% 24.9% 19.9% 16.9% 22.9% BANDS Less than Norm A B C D E A = Most Strongly Engaged Medical Staff B = Strongly Engaged Medical Staff C = Moderately Engaged Medical Staff D = Weakly Engaged Medical Staff E = Most Weakly Engaged Medical Staff Meta 1: Working in a Collaborative Culture Meta 2: Having Purpose & Direction Meta 3: Being Valued & Empowered More More More NORM NORM NORM Less A B C D E Less A B C D E Less A B C D E Sub-Scales 1: Climate for Positive Learning 3: Appraisal & Rewards Effectively Aligned 5: Development Orientation More 34.5 More More 29.8 NORM NORM NORM Less A B C D E Less A B C D E Less A B C D E 2: Good Interpersonal Relationships 4: Participation in Decision Making & Change 6: Work Satisfaction More More More 29.3 NORM NORM NORM Less A B C D E Less A B C D E Less A B C D E 17

19 The table below summarises percentages of all medical staff respondents who were the most engaged (i.e. Bands A and B) and the least engaged (i.e. Bands D and E) for each of the ten MES scales. Percentage Most Engaged (Bands A & B) Percentage Least Engaged (Bands D & E) MEI: Medical Engagement Index Meta-Scale 1: Working in a collaborative culture Meta-Scale 2: Having purpose and direction Meta-Scale 3: Feeling valued and empowered Sub-Scale 1: Climate for positive learning Sub-Scale 2: Good Interpersonal relationships Sub-Scale 3: Appraisal and rewards effectively aligned Sub-Scale 4: Participation in decision-making & change Sub-Scale 5: Development orientation Sub-Scale 6: Work satisfaction Although an examination of the above table shows that the profiles of medical engagement vary across the MES scales, it is also apparent that within each scale there are some variations in the frequency of medical staff reporting high and low levels of medical engagement. For example, 46% of all medical staff respondents (52%) were either most weakly engaged or weakly engaged (i.e. their ratings fell either in Band D or in Band E) with respect to Sub-Scale 5: Development Orientation. Clearly many medical staff would welcome more training to develop their skills and more opportunities to progress their career. In contrast, the frequency of medical staff respondents who were either most strongly engaged or strongly engaged (i.e. their ratings fell either in Band A or in Band b) was highest for Sub-Scale 6: Work Satisfaction (45%) indicating the particular importance of encouraging medical staff to develop a sense of attachment and commitment to shared organisational values.. 18

20 d) Alignment of Medical Ratings and Managerial Perceptions In addition to medical staff completing the MES, a small sample of senior mangers (n = 18 in all) were asked to make an estimate of the percentage of engaged medical staff on each of the ten medical engagement scales. Differences between these estimates and actual percentages of engaged medical staff in this Trust were calculated and they indicate the extent to which managers and medical staff are aligned in their perceptions. Manager's % OVERESTIMATE of Medical Engagement Manager's % & Medical Staff ALIGNED Manager's % UNDERESTIMATE of Medical Engagement -25 Index of Medical Engagement Meta 1: Working in a Collaborative Culture Meta 2: Having Purpose & Direction Meta 3: Being Valued & Empowered On average, senior managers appeared to be well aligned to medical staff in their estimates with only a slight tendency to overestimate Meta-Scale 1: Working in a Collaborative Culture and Meta-Scale 3: Being Valued & Empowered. In this instance, the close alignment of managers estimates of engagement to the corresponding medical ratings suggests a realistic managerial understanding of the demands placed on medical staff at Cardiff & Vale UHB. This informed perception may well serve to ensure managers prioritise the importance of medical engagement and encourage the active promotion of medical staff in planning, designing and delivering services at Cardiff & Vale UHB. 19

21 3) LOCAL QUESTIONS Representatives of Cardiff & Vale UHB had identified a number of local issues and these were included as two rating sections within the MES survey questionnaire in order to provide additional information about medical engagement within the organisation. Each rating section is reproduced below and respondents were asked to rate each item using a five-point level of agreement scale. The two stacked histograms shown below summarise the ranked ratings (i.e. the average level of item scores) of all respondents to each section. Generally, in this organisation... 0% 20% 40% 60% 80% 100% We try new things rather than hold on to the status quo I have regular involvement with the leadership team within my speciality I have the information needed to understand the financial consequences of the decisions I make I feel able to provide the best care to patients within the resources available I am able to keep up to date and informed about changes in plans and policies strongly disagree disagree neither agree strongly agree The medical staff rating of these sections provided a mixed picture of working in Cardiff & Vale UHB. For example, an examination of the ranked histograms shown above reveals that whereas 54% endorsed (i.e. either agreed or strongly agreed ) that they have regular involvement with the leadership team within their own specialties only 28% endorsed the statement that The working arrangements in this organisation facilitate my opportunities to discuss quality, safety and performance with Senior Managers, including the Chief Executive (formally or informally). Similarly, 55% endorsed (i.e. either agreed or strongly agreed ) that the working arrangements in the organisation helped them engage in personal; training and professional development programs, whereas only 29% endorsed the statement that The 20

22 working arrangements in this organisation promote leadership, innovation and change as an intrinsic part of the medical role. The working arrangements in this organisation. 0% 20% 40% 60% 80% 100% Support close working between the service team and medical staff to resolve issues Promote leadership, innovation and change as an intrinsic part of the medical role Facilitate my opportunities to discuss quality, safety and performance with Senior Managers including the Chief Executive (formally or informally) Help me engage in personal training and professional development programmes strongly disagree disagree neither agree strongly agree The stacked histograms shown above summarise the level of endorsement (in percentages) of all medical staff respondents who rated these two sets of local questions. An examination of these histograms shows that some items were associated with a level of acceptance of 50% or more (i.e. these items had been rated either agree or strongly agree by a majority of medical staff respondents) whereas some items were associated with a level of rejection of 50% or more (i.e. these items had been rated either disagree or strongly disagree by a majority medical staff respondents). To assist rapid interpretation, these majority acceptance and majority rejection items are identified on the stacked histograms using a tick or a cross where appropriate and these highlight the broad pattern of medical opinion in the organisation. (Please note that there are no majority rejection items for this organisation). 21

23 4) OPEN ITEMS Three additional items were included within the Cardiff & Vale UHB MES survey questionnaire in order to provide further information about medical engagement within the organisation. The three open items were as follows: Open Item 1: Please suggest ways that the organisation could promote better working arrangements to support care across the integrated care pathway. Open Item 2: Please suggest ways in which the service could enable you to keep up to date about changes in plans and policies. Open Item 3: Please suggest ways in which the service could enable you to become more involved in influencing decision-making about services. The responses to each open item were analysed independently although for some medical staff respondents there was a deal of overlap in the issues that were mentioned in response to each of the three items. Overall, 34.5% of the total medical sample commented on Open Item 1, 31.2% responded to Open Item 2, and 29.6% provided comments in response to Open Item 3. Content Analysis of Open Item 1 Please suggest ways that the organisation could promote better working arrangements to support care across the integrated care pathway. Content analysis of the aggregated open comments for this item revealed that there were several overarching themes which conveyed the key ideas in the combined collection of responses. In order to present the most central issues as described by the medical staff themselves and to enable the reader to rapidly get the gist of current medical concerns, a selected sample of representative comments made with respect to each of these themes are reproduced below:- Theme (a) Management Recognise that experienced clinicians delivering clinical care are likely to have a greater insight into the needs of their services than managers sitting in meetings and offices. Stop senior clinicians and management bullying and harassing us to accept clinical and management decisions imposed on us. I am sure that the paper policies of the UHB are OK but this is a sclerotic organisation with huge organisational inertia in middle management that prevents frontline clinical innovators supporting the UHB strategic direction. Often it feels like doctors are asked to sit in meetings only to agree and any differed opinions or questions to clarify are seen as personal disrespect towards managers and clinical directors. More medics in management positions (with time in job plan to undertake the role, rather than being in addition to existing clinical duties). 22

24 Increase involvement of middle management and board level management directly with clinical staff all we get is forwarded s and have never met any of our managers apart from occasional dealings with our own manager. We have had several years of weak Directorate (medical) management and stalling on many decisions, lack of clarity over remits of Directorate vs. Clinical Board and poor support of the CD, who eventually resigned. Theme (b) Staff Roles Give more initiative to staff to work more hours in the form of extra work schedule I think that would help the patients as it minimises the backlog and provides better care I think it would be useful if staff had knowledge understanding and responsibility in relation to patient management costs. Staffing has not kept up with the rapid relentless rise in volume of work in Radiology there is no time left to think, discuss, reflect or pilot new ideas as we're all fully immersed (and drowning) in the status quo. Promote interdisciplinary working and learning/educational opportunities encourage staff rotation and shadowing opportunities promote secondments across specialities Invest in IT infrastructure and agile solutions to provide tools to assist front line staff in performing their jobs. We need to manage medical staff by delivery not process and provide the resource flexibility for them to succeed. The nurses on the wards feel under pressure to say they are well staffed/coping, but patients will often tell you the nurses don't have time to do everything. I feel that there is a disconnect between clinical boards and lower staff and that the overarching goals are not well communicated. Theme (c) Clinical Work Everyone is excited by the 'exciting new technologies' but the clinical service is very much ignored and only gains attention when things go wrong. Each subspecialty has had a Clinical Lead and therefore those who are not the Lead do not know what is happening in other sub specialities. Build on the cross cutting performance agenda, ensuring clinical boards work together to deliver the desired outcomes. We need to tackle overtreatment and over diagnosis at a practical clinical level. Stop wastage of money and resources by defensive medicine, doing investigations and operations and several clinic attendances : challenge this passing the buck attitude. That is not appropriate for an organisation whose service model is to deliver healthcare, because the purpose of managers is to facilitate clinical developments, not to shape or dictate them. 23

25 Change the clinical director when there is clear evidence of absence of collaborative working, lack of positive engagement with consultant body and micromanagement. More medics in management positions (with time in job plan to undertake the role, rather than being in addition to existing clinical duties). Recognise that experienced clinicians delivering clinical care are likely to have a greater insight into the needs of their services than managers sitting in meetings and offices. We are over managed in that there has been a history of nonclinical managers seeking to dictate to clinicians how they should work. Middle management's default response is no and they are paralysed through fear of spending money to help clinicians improve the systems and to implement better patient care Theme (d) Meetings Have management come to our departmental meetings, understand our issues and help us solve them. As a diagnostic specialty we need to be plugged in to the pathway, have cross directorate meetings to solve pathway issues. Regular meetings with all staffs and engagement of all staffs across the specialities All wards looking after patients with complex needs, should have regular (once weekly) multidisciplinary meetings, to ensure treatment goals are set in a patient centred manner with full sharing of assessments across disciplines, and reduce fragmentary discipline centred care. I have been a consultant for more than 10 years, the chief executive has never met me as an individual. Issues are forced to the top of the 'crisis management pile' for a very limited time, meetings take place and then the issue seems to be forgotten by the next, most urgent crisis. Often it feels like doctors are asked to sit in meetings only to agree and any differed opinions or questions to clarify are seen as personal disrespect towards managers and clinical directors. More regular multidisciplinary meetings, in small groups. Regular inter-speciality meetings through Q&S sessions There are too many meetings which very often do not achieve anything at all. Develop a common room for senior medical/nursing/managerial staff to meet informally, as informal discussions can lead onto big ideas. Theme (e) Directorates & Specialties Better communication between directorates and between primary/secondary/tertiary care Integrate Therapies into all Directorates rather than being managed separately. 24

26 If more consultants are employed in one directorate funding for us should be automatic and not require us to write business case after business case to get a new post/sessions. There is a lack of communication within the Directorate. Directorate management repeatedly ignore proposed improvements suggested by medical and senior nursing staff. Have to engage in better review of standards of middle managers and directorate managers to focus on medical empowerment and quality improvement. Increase flow of information to learn from other teams within directorate, distribution of information presented at staff forum to all medical and nursing staff working in the Directorate since only the minority can attend. More robust criteria for early defining and placement of patients on specialty wards patients commonly undergo too many ward moves, contributing to increased length of stay and poor patient experience Theme (f) Teamwork Ensure that IT supports the working of teams across the divides of University, Primary and Secondary care, WAST and Public Health Wales. Pathways of integrated working can be facilitated by teams being able to use the same IT, S drives etc. Working should be truly multidisciplinary and consultants show not brow beat other team members into being in total agreement with their personal opinions. Consultants set a poor example to other team members by their lax behaviours. Integrated team working on wards. Embed social workers within ward teams to integrate existing community assessments into acute care plans and facilitate early discharge. Increase flow of information to learn from other teams within directorate, distribution of information presented at staff forum to all medical and nursing staff working in the Directorate since only the minority can attend. Those managers need to be seen as part of the clinical team in each paediatric specialty, who bring particular skills and expertise, and they need to be accountable to the clinician leading that team for ensuring management needs of that specialty are adequately met. The nurse manager and other senior team who make some of the decisions has not been involved in direct patient care for long time. Strengthen communication between management team and consultant body in both directions. Content Analysis of Open Item 2 Please suggest ways in which the service could enable you to keep up to date about changes in plans and policies. Content analysis of the aggregated open comments for this item revealed the following themes which are shown below together with a sample of verbatim open comments most applicable to each one. 25

27 Theme (a) seems the default option and is over burdensome and unreliable way of informing staff. Increase the storage capacity of inbox folder of s. Facilities to be able to access work from outside the hospital. updates In-house meetings no point if there aren t any improvements to notify staff about I personally receive too many s which I automatically delete unless I see its relevance to me e.g. newsletters, guidance, etc. Better information via and distribution lists. seems the default option and is over burdensome and unreliable way of informing staff. Improve directorate related distribution of s from UHB since they can be totally irrelevant. Filter down things in a more meaningful summary rather than endless s about links to new or updated policies which may or may not impact greatly on my work. It is better to send a succinct summary on a quarterly basis rather than bombard clinicians with multiple s daily. Theme (b) Meetings and Updates A CD and Divisional director who actually turn up to meetings regularly, take minutes, act on problems in a timely way and feedback. Dates of scheduled meetings to discuss proposed changes further could be opened up to interested individuals. May I suggest publishing all that is said in Management and Executive Board meetings on the intranet so every comment can be read by any member of staff. Regular lunch time meetings (providing food to encourage people to attend). To have notice about meetings well in advance in order to plan appropriately. Clinical directors should have the ability to engage in these meetings without penalising colleagues for sharing their views. Continue regular meetings with the directorate management team, perhaps on a more frequent basis. Quarterly or six-monthly meetings with the executive team and the individual specialities I have only had contact with them in a 'crisis' situation. Theme (c) Staff Involvement Continue regular departmental staff forums 26

28 More face to face engagement between senior leaders and front line staff Clarity in job planning and avoid procrastination which is very well known in this department The management team needs to be proactive in engaging staffs To ensure adequate time in job plan for staffs to develop professionally rather than being pressurised to provide acute cover for gaps in rota or colleagues Less General Haig directing and barking orders from behind a desk, and more Colonel Tim Collins getting out there and talking to frontline staff to have bidirectional sharing of information and inspiring but not patronising them. More informal discussion within the senior staff body would help and the appropriate environment to do this. By involving senior medical staff from the early stages. Theme (d) Policies and Plans Every group of staff should be formally at least monthly informed about changes in plans and policies that occur in its speciality. Policies and plans do not reflect our perceptions or needs and feel imposed rather than organic. There needs to be more of a connect between policy at organisational level and at Directorate and practitioner level. Provide short summaries of key policies /plans as not time to read them all up - encourage dissemination of information through directorates from the top down. We do get statements and policy documents from the chief exec, but the thing is whilst these always say a whole load of laudable things and promote principles that we can all agree with, they seem a million miles away from what is actually happening on the ground. Have a single simple portal that can be accessed on any computer and identify policies relevant to everyone clinicians etc. Content Analysis of Open Item 3 Please suggest ways in which the service could enable you to become more involved in influencing decision-making about services. Content analysis of the aggregated open comments for this item revealed the following themes which are shown below together with a sample of verbatim open comments most applicable to each one. Theme (a) Change Management There have been far too many layers of bureaucracy and management for many years, which strangulate change and result in endemic managerial sclerosis. There is a need to devolve budgets (including income) and decision-making authority, and abolish at least 2 tiers of management. The active engagement of managers with the appropriate people (end users or their Consultants) where service development or change is suggested. Reduce the number of managers who have no power to make decisions. 27