Performance Management

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Performance Management

• Insight
• September 27, 2006
• The Old Mill

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Notes

• No need to take notesThis presentation and a lot
  more material is on these issues is available on
  our web sitewww.healthandeverything.orgFor more
  information you can write to me
  sholom_at_glouberman.com

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The NHS

• The Blair government created strategic health
  authorities (SHAs) in 2002 specifically to
  performance manage the newly created primary care
  trusts (PCTs).
• There was thus a four year experiment with a
  large scale performance management effort worth
  looking at.

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Performance Management NHS 2002-2005
Minister of Health
Department of health
28 Strategic Health Authorities
200 Primary Care Trusts
180 Acute and Mental Health Trusts
1.000.0000 Employees
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My Role

• I have been meeting semi-annually with a
  representative cross section of the NHS from 1990
  to review the state of play and changes that have
  occurred
• I consulted to a strategic health authority from
  2001 to 2005
• I met with them 4 times a year to see how they
  were doing and lend a hand in their efforts.
• I also consulted to a Primary Care Trust from
  2001 to 2003
• I met with them 5 times and helped with their
  planning efforts

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Introducing Performance Management in the UK

• A specific publication on performance management
  was prepared in 2002, but is no longer available
  on the internet or in hard copy
• So I have used standard sources to give an
  overview of Performance Management
• Various Outlines and Reports are available that
  helped to describe how it was implemented in the
  NHS

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Performance management
Performance management is the systematic process
by which an organization involves its employees,
as individuals and members of a group, in
improving organizational effectiveness in the
accomplishment of its mission and goals.
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Employee performance management includes

• Planning work and setting expectations,
• Continually monitoring performance,
• Developing the capacity to perform,
• Periodically rating performance in a summary
  fashion,
• Rewarding good performance.

Planning
Monitoring
Rewarding
Developing
Rating
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Employee performance management includes
Planning
Monitoring
Rewarding
Developing
Rating
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Planning

• Set performance expectations and goals
• Involve employees in the planning process
• help them understand goals (what why and how)
• Establish elements and standards of performance
  appraisal
• that are measurable, understandable, verifiable,
  equitable achievable.
• Hold employees accountable as individuals
• Plans should be flexible
• Plans should be discussed often and not seen only
  when formal ratings are required.

Planning
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Planning in the NHS Trust Involvement

• Introduction of 3 year Local Delivery Plans to be
  prepared by individual trusts
• Bottom up planning to involve all local agencies
  with support from the SHA
• Stabilization of planning and funding over 3 year
  periods

Planning
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Monitoring
Monitoring

• Monitor continually.
• Consistently measure performance
• Provide ongoing feedback on progress toward
  goals.
• Compare performance against their elements and
  standards.
• Change unrealistic or problematic standards
• Identify and correct unacceptable performance
  quickly

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Monitoring in the NHS

• Three Major agencies to monitor and assess the
  system
• NICE National Institute for Clinical Excellence
• To review standards and improve clinical practice
  
• CHI Commission for Health Improvement
• To consider impact on health of the nation
• Audit Commission
• To monitor and assess fonancial and operational
  management

Monitoring
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Developing
Developing

• During planning and monitoring of work
• Deficiencies become evident and can be addressed
• Successful employees can be helped to further
  improve
• Evaluate and address developmental needs
• Increasing capacity to perform through training,
• Give assignments to introduce new skills or
  higher levels of responsibility,
• Improve work processes
• The above encourage good performance
• Strengthen job-related skills
• Help employees keep up with changes in the
  workplace

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Developing in the NHS

• Creation of the Modernization Agency
• Seconded the best development officers
• To help define the shape of the New and modern
  NHS
• Then to identify and develop the new skills and
  competencies needed for the new NHS
• To identify and deal with development issues
  quickly

Developing
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Rating

• Organizations need to know who their best
  performers are.
• Rating allows you to compare performance over
  time or among various employees.
• Evaluates employee or group performance against
  the elements and standards
• Assigns a summary rating of record for each
  employee.
• based on work performed during an entire
  appraisal period.
• has a bearing on various other personnel actions
• granting within-grade pay increases
• determining additional retention service credit
  in a reduction in force.

Rating
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Rating in the NHS

• An Annual Report on the performance of individual
  organizations
• Linked to the measurable targets
• Uses a three star rating system
• 0 stars poor
• to 3 stars excellent
• Individual Managers and organizations are rated
  using these performance measures at every level
  of the system

Rating
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Rating in the NHS 45 Measurable Targets
Planning
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Rewarding
Rewarding

• Recognize employees, individually and as members
  of groups,
• Acknowledge contributions to the mission
• All behavior is controlled by its consequences
• formal and informal
• positive and negative.
• Informal recognition is constant and ongoing like
  saying "Thank you
• More formal rewards include cash, time off, and
  many non-monetary items.
•  

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Rewarding in the NHS
Rewarding

• The main group reward in the NHS is through the
  creation of Foundation Trusts
• Individual organizations that have far more
  independence and can increase their local rather
  than national reporting relationships
• This is replicated inside SHAs and indeed inside
  the existing trusts
• Successful managers move up quickly
• A successful CEO of an SHA received a knighthood

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2006

• In 2006 the Ministry of Health reduced the number
  of strategic health authorities to 14 and
  radically changed the primary care trusts.
• They merged the monitoring agencies
• Performance Management is no longer the flavour
  of the month
• How did it all go so wrong? Not that anyone
  admits it.

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Planning in the NHS Trust Involvement
Planning

• The 3 year Local Delivery Plans (LDPs) took two
  years to frame
• Local trusts did not perform well
• The SHAs believed that they did not have the
  planning capacity to prepare the extensive
  documentation.
• LDPs were renewed annually
• LDPs were required top down and the bottom up was
  to get them done in an acceptable way
• Annual revisions reduced the stability that was
  expected
• The SHAs could not performance manage trusts
  adequately and were therefore largely merged into
  larger less directive organizations
• What would bottom up planning be in the NHS?

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Planning in the NHS Targets

• The priority targets were largely met or fudged.
• Some incidents of faking data
• Some incidents of meeting stated targets but
  subverting the real meaning
• Widespread hidden overspend
• Government boasted of success in reducing all
  waiting times
• Head of NHS was fired for 1Billion accumulated
  deficit that emerged suddenly
• What does measurable really mean?

Planning
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Monitoring in the NHS

• Three Major agencies to monitor and assess the
  system disagreed about the state of individual
  trusts that they examined
• They functioned as largely independent and
  somewhat competing inspectorates
• They disagreed about what the standards meant
• They also overloaded individual trusts with
  monitoring demands
• They were merged into one organization that is
  now much more hierarchically connected to the
  Ministry.

Monitoring
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Developing in the NHS
Developing

• The Modernization Agency was disbanded in 2005
• (The government declared it to be a success and
  closed it down)
• The best development officers had been stripped
  from local organizations and now would not go
  back
• The performance management of development issues
  was largely done through punitive measures at the
  SHA rather than the Modernization Agency.
• Many executive level managers of trusts lost
  their jobs.
• The failure to perform old skills like those
  associated with budget management was widespread

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Rating in the NHS

• The Annual Report was awaited with bated breath
  because your job depended on it
• Linked to the priority targets so other
  non-targeted areas suffered
• Targets continue to be attacked constantly
• The three star rating system had its downside
• 0 stars pretty much meant that at least the CEO
  was fired
• 3 stars meant that you became high profile
• Individual Managers and organizations are rated
  using these performance measures at every level
  of the system

Rating
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Rating in the NHS
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Rating in the NHS

• Key targets
•  

• AE emergency admission waits (12 hours) 
• Cancelled operations not admitted within 28 days 
• Financial management 
• Hospital cleanliness
• Improving Working Lives 
• Number of inpatients waiting longer than the
  standard 
• Number of outpatients waiting longer than the
  standard 
• Total time in AE 
• Two week cancer waits

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Rewarding in the NHS

• The main reward in the NHS is through the
  creation of Foundation Trusts
• There is a serious question about how these
  organizations link to the rest of the NHS
• This has consequence to everything from funding
  flow to patient flow.
• Individual organizations that have far more
  independence and can increase their local rather
  than national reporting relationships
• There is much talk about the future of these
  organizations
• Punishment for failure seems more in the air
  motivator than reward for success
• The knighted head of the NHS Sir Nigel Crisp lost
  his job over these efforts

Rewarding
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The Law of Unintended Consequences

• With all good intentions this massive effort to
  implement performance management failed
• Does this mean that performance management will
  go the way of other similar management ideas?
• Why did it fail? Can it be recuperated? Or should
  it simply cross the ocean to be implemented in
  Ontario?
• I have some closing thoughts

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Following a Recipe A Rocket to the
Moon Raising a Child
Complicated
Complex
Simple

• Formulae are critical and necessary
• Sending one rocket increases assurance that next
  will be ok
• High level of expertise in many specialized
  fields coordination
• Rockets similar in critical ways
• Relative certainty of outcome
• Optimism re results

• Formulae have only a limited application
• Raising one child gives no assurance of success
  with the next
• Expertise can help but is not sufficient
• Every child is unique
• Uncertainty of outcome remains
• Optimism re results

• The recipe is essential
• Recipes are tested to assure replicability of
  later efforts
• No particular expertise knowing how to cook
  increases success
• Recipes produce standard products
• Certainty of same results every time
• Optimism re results

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Analysis

• Health care organizations and systems are complex
• Recipes wont work and their application will
  have unintended consequences
• Performance management like many other flavours
  of the month can be useful but should be applied
  with great care and foreboding while carefully
  considering the complexity of local conditions