Independent External Evaluation of KSS Deanery’s Leadership Fellowship Programme (Summary)
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KSS School of Clinical Leadership Fellowship Evaluation
Summary Report: Independent External Evaluation of KSS Deanery’s Leadership Fellowship Programme
Sue Miller & Dr Sue Balint, August 2010
University of Westminster 35 Marylebone Road London NW1 5LS 020 7911 5000
Sue Miller, August 2010
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KSS School of Clinical Leadership Fellowship Evaluation
Executive Summary
KSS Deanery’s Clinical Leadership Fellowship programme commenced in September 2009. Eight specialist registrars began a one-year full-time Leadership Programme, combining a Masters degree, delivered by Brighton Business School, with a placement in a service unit. In January 2010, a team from Westminster Business School, University of Westminster, were commissioned to carry out an independent evaluation of the Fellowship. Their brief was to examine the experiences of the Fellows, those managing and delivering the programme in the Deanery and at Brighton, and the senior management mentors facilitating the work placements. The evaluators were also required to consider how far elements of the business case put forward in support of funding for the programme had been achieved. The evaluation team used various methods: a review of documentation, on-line questionnaires for completion by Fellows and by their designated mentors, focus groups, interviews and observations of meetings. The programme is distinctive in that it includes both primary and secondary care, uses comentors, ‘Leadership Facilitators’, in the workplace, and involves a management qualification at Masters level tailored specifically to clinical leaders. The decision to recruit senior registrars and to require them to complete a full-time, one year programme, without clinical responsibilities, also represents a different approach from that adopted by other Deaneries in their response to the Lord Darzi’s Next Stage Review (Department of Health, 2008). Generally, the design of the programme has been commended: the combination of a fulltime Masters programme and work placements with formalised facilitator roles for senior managers is deemed an effective model by all participants and contributors to the programme. A marriage between academic and practitioner perspectives has been achieved to a large extent and a learning community has been created, although there remain areas where a common understanding is yet fully to be developed. Whilst, initially, there was some lack of clarity and understanding about roles, responsibilities and the interplay between the academic programme and the workplace, the Deanery has played a very significant facilitating role in overcoming uncertainties. Whilst KSS Deanery’s programme is about developing leadership capability in specific individuals, it is also about sowing the seeds of change in groups and organisations and about building connections and impacting on the wider community and the worlds in which the participants interact and this has informed the approach. The programme has, therefore, been founded on fostering relationships and providing opportunities for dialogue.
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KSS School of Clinical Leadership Fellowship Evaluation The criteria for success identified by the different players at the start of the programme have largely been met. These included good completion rates, educational and clinical effectiveness, positive impacts on work organisations and changes in the clinical setting as a result of the programme, the creation of ‘new ways of being’ in the Fellows, the development of Fellows’ confidence and their increased understanding of ‘the system’, and a desire that they will ‘go on to be effective leaders over and above their peers’. This latter is a longer-term goal but there is evidence that the other objectives have already been achieved. Lessons have emerged from this first iteration of the Fellowship. Giving the participants opportunities to experience ambiguity and complexity in a clinical setting and to examine these experiences in conjunction with senior managers who are genuinely interested in the learners’ perspectives and offer their own insights in return – an approach which values mutual learning – is of prime importance. Also fundamental is the development of a selfquestioning, critical and reflective approach which is practised and exercised both in the classroom and the workplace. Generating a willingness to struggle to achieve change and a determination to keep the patient at the forefront is also important, though difficult to ‘design’ into the programme. Embedding this mindset depends not only on the careful selection of suitably motivated trainees, but also on the ability and desire of the various contributors – facilitators, academic tutors and Deanery representatives – to model appropriate behaviours and attitudes and to inspire the participants to want to act. KSS Deanery’s Leadership Fellowship programme has made a contribution to the Strategic Health Authority’s strategic aim to build a pool of ‘excellent’ clinical leaders, with increases in the Fellows’ leadership capability reported by Fellows and their Facilitators. It has helped to raise the profile of clinical leadership and to engage a wider audience, while contributing to workforce development – of the Fellows’ themselves and of others who have been involved in the programme. Elements of the business case originally set out for the programme have, therefore, been achieved with some, if limited, evidence already of improvements in patient outcomes as a result of participation in the programme. The potential for future impact is considerable, as a consequence of the implementation of the Fellows’ recommendations and service improvement plans, through their continuing contribution to the development of their services, and as a result of the wider organisational learning achieved through their insights. This longer-term impact will be heightened if the Fellows can sustain their motivation and learning, if there is continuing investment in their development and if they find employment in organisations whose cultures encourage the deployment of leadership capability.
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KSS School of Clinical Leadership Fellowship Evaluation
Summary Report
1. Background and impetus for the Fellowship programme
The Darzi Report highlighted the failure to develop competent clinical leaders across the NHS, and emphasised their vital importance in the transformation of services, and in the enhancement of the patient experience and patient outcomes. KSS Deanery was required to respond to this report which proposed the establishment of Clinical Leadership Fellowships (paragraph 34 ‘Next Stage Review: High Quality Care for All’) and was keen to do so. Both the Dean Director and the Deputy Dean Director/GP Dean were already demonstrating a commitment to expanding leadership education for clinicians, and the Fellowships were one of the strands agreed as part of the establishment of a KSS School of Clinical Leadership in October 2008. The subsequent expansion of the number of Fellows (for educational reasons) – from four to eight – led to a requirement for additional MPET funding, specifically for additional Fellowships, and a business case to extend the Fellowship programme was approved in February 2009. The key drivers remained those identified in the business case set out and approved for the setting up of a School of Leadership. The KSS Fellowship can, therefore, be seen in the context of a bigger strategy to improve and expand clinical leadership education which is being embraced by the Deanery. The business case for the establishment of the new School of Leadership cites a range of potential outcomes – improving patient safety, improving the patient experience, service improvement, leadership, workforce planning, strategy and development – and, by implication, it is hoped that the Fellowship will ultimately contribute to these. It is, however, recognised by those involved in the programme that finding evidence to prove a link between the Fellowship and these outcomes is not straightforward and it may take time to emerge.
2. The programme’s components
Eight specialist registrars commenced a one-year full-time Leadership Programme in September 2009, combining a Master’s degree with a placement in a service unit. The programme is distinctive in several respects: the involvement of both primary and secondary care, the use of co-mentors, ‘Leadership Facilitators’, in the workplace, and the inclusion of a management qualification at Masters level tailored to the learning needs of clinicians. The decision to recruit senior registrars, i.e. doctors at a relatively early stage in their careers, and GPs immediately following training, was founded on a belief that those who are interested in management and leadership should be given ‘a genuine opportunity.....earlier in the cycle’ (Dean Director). Also a significant part of the approach is the employment status and length
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KSS School of Clinical Leadership Fellowship Evaluation of the programme with the Fellows completing a full-time one year programme, without any clinical responsibilities. The reasoning is that this is the most viable arrangement both for the host Trust and the Fellow.
3. Underlying philosophy of learning and of leadership
Fundamental to the programme is the relationship between the academic aspects of the programme and the workplace element. The Fellowship is founded on a particular view of education and learning: ‘learning...taking place in the real life, complex, problematic, messy workplace, rather than simply in....a kind of ivory tower academy...’ (Head of Education) The desire to bind together ‘practice and the academy’ has informed the programme, with the appointment of leadership facilitators and a conscious emphasis on getting ‘the workplace completely united with the University.’ The relationships involved in learning are also given a prime place in the Deanery’s approach. Allied to the approach to education is the conception of leadership. This is expressed in different ways by the key architects of the programme – the Deans and Heads of Education in the Deanery. The GP Dean expresses a requirement for the academic programme to provide a systematic approach ‘to management in addition to leadership’, but with clinical/patient benefit being the ultimate goal - ‘a clinical leader is someone who can motivate others to make change for clinical benefit, for patient benefit.’ (GP Dean) The Head and Deputy Head of Education also share a particular concern to explore the meanings of leadership and management in the context of a clinical environment but express it in this way: ‘In this environment, the relationship needed to be reversed... the larger term is leadership......Leadership is the hard skills; the small term is management......’ These positions have informed the design of the programme.
4. Independent External Evaluation
4.1 Evaluation brief
KSS Deanery commissioned an independent evaluation of the programme in January 2010, with a brief to focus particularly on the following: The organisation of the programme and the business and educational infrastructures supporting it The experience of the full-time Clinical Leadership Fellows participating in the programme
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KSS School of Clinical Leadership Fellowship Evaluation The experience of the Course Team – i.e. the academic staff providing the programme and the ‘Leadership Facilitators’ (senior managers from the local education providers who facilitate the Fellows’ learning within the workplace) The experience of the Academic and Clinical Heads of the School of Leadership The achievement of elements of the business case (which was identified in support of the establishment of a School of Leadership within the Deanery) Information and perceptions were sought about the programme as follows: Context - the circumstances under which the programme was brought into being; why it is being funded; the expectations of the various stakeholders Administration – the recruitment and selection of learners; the organisation and usefulness of the briefing, support and follow up arrangements Processes – the feelings of the participants about the learning process; what they thought they were learning and how they were learning; the meaning the various events and elements had for the participants; the perceptions of all those involved Inputs - the design, planning and delivery of the programme Outputs – changes in the learners; organisational outcomes; unintended outcomes
4.2 Methods
A range of methods were used to evaluate the programme: Review of programme documentation (February 2010) Observation of a planned meeting of Leadership Facilitators (March 2010) Interviews with key members of the Deanery – Dean Director, Deputy Dean Director/GP Dean, Head of Education, Deputy Head of Education, Clinical Head of School of Leadership, Academic Head of School of Leadership – to identify how different key players view the programme, their role in its genesis and delivery, and how they visualise success. (April 2010) Online questionnaires issued to all Clinical Fellows – to explore their experiences and the learning they have achieved, and to highlight their perceptions of the contribution of different elements of the programme (April 2010) Interview with the MSc Course Leader (May 2010) Facilitation of a focus group comprising the Clinical Fellows (May 2010) Online questionnaires issued to all Leadership Facilitators – to explore their perceptions of the organisation and administration of the programme, their own
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KSS School of Clinical Leadership Fellowship Evaluation roles and contributions, and the perceived impact of the programme on their Fellows and their service units (June 2010) Facilitation of a focus group comprising Leadership Facilitators (June 2010) Telephone interview with a Leadership Facilitator (July 2010) Attendance at Fellows’ session at the Deanery’s leadership conference – ‘Are all doctors leaders?’ (July 2010)
5. Findings and recommendations
Summaries of the key themes which emerged in the qualitative analysis are provided below in relation to each aspect of the programme, with accompanying recommendations.
5. 1 Organisation and administration
The genesis of the Fellowship reflects its place as part of a larger leadership strategy and set of developments within the Deanery. The programme was developed over time as new appointments were made and new structures were put in place. Attention was given initially to the academic aspects and the Fellows were recruited before the flesh was put on the bones of the arrangements. This meant that work was done ‘retrospectively’, some immediately prior to the start of the programme, in helping Fellows to understand what would be involved in undertaking the Fellowship and in clarifying roles for the Facilitators. Successes: The selection process has resulted in high calibre, self-motivated Fellows. The Deanery has responded to Facilitators’ concerns and uncertainties throughout and has provided ongoing opportunities for dialogue and discussion about the organisation and operation of the programme. Issues and areas of challenge: Application process – the organisation of the academic course and timetable for it was not clearly explained in the initial briefing documentation. Briefing of Leadership Facilitators – the Facilitators were not wholly clear about their roles and the importance and requirements of the Masters programme at the beginning of the programme (although this understanding developed over time.) Induction in the workplace - there was some variation in the quality of induction, with some Fellows being given insufficient orientation when they first embarked on their work placement. Organisation of action learning sets – a lack of fixed arrangements impacted on the Fellows’ commitment to these.
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KSS School of Clinical Leadership Fellowship Evaluation Recommendations: Ensure that the timetable for the academic programme is well-communicated in the recruitment literature. Deanery to set minimum requirements for workplace induction with suggestions regarding an appropriate process - in terms of briefings, introductions to key personnel and physical provision (desk, telephone etc.) Schedule and communicate dates for meetings of action learning sets at the beginning of the programme.
5.2 The Academic Course
All Fellows are working towards an MSc Management (Leadership for Clinicians) which is delivered by Brighton Business School and led by an MSc Course Leader. The inclusion of a management qualification at Masters level was deemed a fundamental, and unique, part of the approach to the Darzi initiative by KSS Deanery, by desire specifically of the Head and Deputy Head of Education. The course involves a series of modules, all of which (in their entirety) are specific to this programme, but a number involving teaching of the Fellows alongside some of Brighton’s MBA Public Services students. The Fellows complete different assessments from their MBA counterparts and have an additional day of input. Other modules are taught exclusively to the Fellows, two by staff from the Deanery – namely ‘Leadership & Ethics’ and ‘Organisational Learning & Leadership’. The decision to expand the number of Fellows to eight was a result of the need to ensure that the delivery of such modules was educationally viable. Each module requires completion of a project, drawing on research and experience in the workplace, and a reflective statement – with a final larger integrative project. Successes: The academic course has been well-received by Fellows and Facilitators. The course content, tutor input and the guidance given by the Course Leader have all been rated very positively. The assessment requirements of the academic programme have been an effective vehicle for ensuring that Fellows explore different aspects of organisation and management and have required them to gather and examine evidence. Fellows have achieved significant learning from the academic course and it has offered them concepts and tools which they can apply in the workplace (see further below, in discussing impact.)
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KSS School of Clinical Leadership Fellowship Evaluation The difference in approach between the Business School and the ‘Deanery modules’ has enhanced the Fellows’ academic experience, although requiring acclimatisation to different ‘languages’ and styles of teaching and learning. The course has helped Fellows to recognise the fact that management and leadership is not about ‘right answers’ but about coping with ambiguity and complexity. Issues and challenges: The Leadership Facilitators would have valued more detail about the content of the academic programme and its requirements in terms of projects and assignments. Completing academic assignments alongside other demands has been challenging for most of the Fellows. It has been difficult for Fellows and their Facilitators to find an effective balance between the different elements of the programme to prevent the Masters from overshadowing other aspects of the workplace component. There has been some reluctance by the Fellows to use practitioner research for their academic assignments: the Deanery is conscious that they could expand their learning opportunities by adopting this approach. Fellows are unfamiliar with the academic literature around leadership and would have appreciated more background and formal input before exploring ethical issues. Fellows see the academic course as being more about ‘management’ than ‘leadership’, with their leadership learning largely taking place in the workplace. How far this is an issue is worthy of further exploration and discussion. Recommendations: Ensure that Fellows are fully aware of the pressures, time commitment and challenges involved in pursuing the MSc alongside involving themselves fully in their work placements. Provide a mechanism in addition to formal meetings for informing Facilitators about the content of the academic programme and accompanying assignment requirements. Expand the meaning of ‘research’ in the minds of the Fellows through an extended session on research strategies and methodologies. Establish the prior knowledge of the Fellows before they start the formal programme, and provide background information and required reading before they enrol.
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KSS School of Clinical Leadership Fellowship Evaluation
5.3 The Workplace Component
Brighton Business School has long been using work-based projects and completion of these academic assignments requires an organisation on which to draw. This approach accords with the Deanery’s concern to ensure that there is a unity between the academic and praxis and the requirement to offer a Fellowship which allows the development of leadership attitudes and behaviours. Thus all Fellows have a placement with a local education provider (LEP). Four of the seven Fellows, (the eighth Fellow has been absent on maternity leave for much of the programme), are in secondary care, with the remaining three attached to a PCT. In designing the programme it was recognised that Fellows would need support in the workplace in order to negotiate access and to provide a sounding-board, hence the appointment of ‘Leadership Facilitators’. It was also acknowledged that this person needed to be someone who was well-respected and relatively senior, as has been the case in each LEP. There have been varying interpretations of the role of the workplace component, with some - Fellows and Facilitators - seeing it mainly as a source of projects for the Masters programme and with Fellows being allocated (or finding) tasks accordingly. For others, there is a wider interpretation of the contribution of the work placement – with Fellows having involvement outside their Masters’ projects and assignments. This latter approach is one which the Deanery welcomes. The degree to which Fellows are required to find and/or delineate their own projects also varies as does the way in which the different Facilitators have perceived their roles and contributed to the programme (to be discussed further in a separate section of the report below.) Successes: There were a number of examples of involvement by Fellows in teams and activities across the organisation – outside the requirements of the academic programme. These Fellows have participated more completely and contributed to a range of work streams as a consequence of this involvement. All Fellows have had exposure to the wider workings of the NHS and to previously unfamiliar aspects of organisational life. Meetings organised by the Deanery and involving the academic Course Leader and the Facilitators have brought the workplace and the academic components closer together. Experiences in the workplace have reinforced learning from the course that leadership requires a different mindset from that engendered by clinical training.
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KSS School of Clinical Leadership Fellowship Evaluation Issues and challenges: There has been significant variation in the level of integration and involvement of the Fellows and in their degree of exposure to different aspects of organisation: a difference between those in PCTs and others in hospitals was evident, with the former having fewer opportunities to become involved. The PCT Fellows, to some extent, were perceived by others, and perceived themselves, to be observers rather than participants. It has been difficult to achieve a wholly common understanding about the role of the workplace and its relationship with the academic programme. Whilst discussions between the Course Leader and Facilitators have assisted in this, a lack of full attendance by Facilitators and a lack of connection to all elements of the programme by the academic tutors at Brighton mean that the different parties are not fully cognisant of each other’s approach and perspectives. Recommendations: Define the relationship between the workplace and the academic programme for Fellows and Facilitators and encourage both parties to see the work placement as more than a source of academic assignments. Encourage academic tutors and Leadership Facilitators to communicate with one another, and emphasise the value to Facilitators of attending some of the teaching. A possible approach might be to build the occasional joint session into the teaching programme or to involve the Facilitators in asking questions and providing feedback on an ‘in-class’ case study presentation by Fellows as part of the academic course. Incorporate some joint projects between Fellows in primary and secondary care to ensure that they have exposure to a range of contexts and to build partnerships. Monitor the work experiences of primary care Fellows and seek ongoing feedback from their Facilitators to ensure that the Fellows are being made aware of how they can apply their leadership skills in different settings and contexts and feel confident and equipped to do so.
5.4 The Role of the Leadership Facilitators
The Deanery’s model of ‘Partnership in Practice’ with its emphasis on ‘collaborative, participative....working relationships’ and its concerns to unite the University with the workplace mean that the ‘leadership facilitators’ are seen as ‘an absolutely crucial part of the development of the programme.’ (Head of Education). The School conceives these leadership facilitators as quite distinct from mentors, in that ‘the role of the facilitator wasn’t
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KSS School of Clinical Leadership Fellowship Evaluation to tell people what to think or how to think.....’ Instead they are there ‘to open doors, to provide access....to facilitate.’ Embedded in this is the notion of mutuality – the leadership facilitator component of the Fellowship is described as ‘a co-mentoring programme’, (Head of Education), with the implication that there will be mutual learning, with an emphatic requirement that Fellows are not simply to be ‘done to’ but are actively involved in exploring possibilities, opportunities and meanings with their facilitators, who themselves need to develop in their roles: the Deanery is not only teaching a Masters programme but ‘we’re also actually teaching, informally, a leadership facilitator programme.’ (Deputy Head of Education). Successes: All Facilitators have contributed to their Fellows’ learning, playing a variety of roles. There are some examples of outstanding support and mutual learning. Acting as a Leadership Facilitator has been a source of satisfaction and of valuable insights for a number of those who have taken on the role. Issues and challenges: For some Facilitators, their contribution to the programme is to some extent compromised by their lack of time and availability. The relationship between some Fellows and their Facilitators, whilst making an important contribution, could be more facilitative. Recommendation: Specify the role of the Facilitator and make expectations explicit and specific regarding time commitment and involvement. Communicate these at an early stage.
5.5 The Deanery and the Fellowship: the Leadership Portfolio
A further component of the programme is a portfolio which records the Fellows’ learning and development over the period of the Fellowship. Students have been required to self-assess themselves against the KSS Standards for Leadership at the beginning of the programme, and then to revisit these to document their progress throughout. (It should be noted that the nature of these standards and assessment against them is outside the scope of the evaluation.)
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KSS School of Clinical Leadership Fellowship Evaluation Fellows are expected to keep a learning log recording their activities, achievements and reflections and it is hoped that they will discuss these with their Leadership Facilitators. A successfully completed portfolio and associated viva, (conducted by the Head of Leadership and one of the Facilitators), where each Fellow presents their achievements in person, results in a Certificate of Completion of the Leadership Fellowship, which can be awarded regardless of success or otherwise on the Masters programme. Successes: The portfolio has provided a vehicle for provoking reflection and for prompting conversations about development. Issues and challenges: Both Fellows and Facilitators find the language and paperwork involved in the portfolio cumbersome. There is some lack of understanding about what is required and how to go about making best use of the portfolio. There are concerns by Fellows about confidentiality, meaning that they feel inhibited about recording all their reflections. Some Fellows have found it difficult to rate themselves and thus to track their progress. Recommendations: Where possible and appropriate, simplify the format and the language of the portfolio, using examples to demonstrate the relevance of the different competences and to enable Fellows and Facilitators to get behind the language. Reassure Fellows that records of learning will remain confidential. Discuss the portfolio on the MSc course, as well as in the workplace and at the Deanery, both to ensure that it assumes more importance and to heighten the interplay between the academic and workplace components, with the ‘practical’ aspects of leadership being given some exposure in the academic context. This would develop further the Fellows’ understanding of the relationship between leadership and management, and between practitioner and academic perspectives, and help them to make more sense of the practical implications of their learning.
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5.6 Action Learning Sets
One of the intended components of the programme was action learning. Two action learning sets were initiated, to be facilitated initially by the Course Leader at Brighton. These have rarely met and are thus reported by all parties as having made only a very limited contribution to the Fellows’ development. Two Fellows recognise the potential contribution of action learning sets and have expressed their disappointment. This disappointment is heightened by the fact that ‘the first one was really good’ – and it is acknowledged that it did achieve something: ‘I think it got us into a way of talking about stuff that we wouldn’t necessarily.’ There is a sense, however, in which the Fellows feel that they have become one informal action learning set. There is some debate in the School of Leadership about the purpose and continuing place of action learning sets in the Fellowship programme for the future – their possible contribution in bringing together clinicians from different services to develop partnerships is seen as a potentially significant benefit, particularly since this is something which could continue beyond the life of the programme. Successes: A number of Fellows found the initial meeting of their Action Learning Set very helpful. This initial meeting has spawned continued informal mutual learning amongst the Fellows. Issues and challenges: There is a lack of commitment by Fellows to formal, facilitated meetings.
Recommendation: Emphasise the value of action learning sets and their place in the programme by publishing a timetable for meetings in advance and building in a mechanism for ensuring that they are given time and attention by the Fellows – for example, an associated assessment, or a requirement for a record/observation or feedback by the Fellows on the process and the progress of their set.
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5.7 The Partnership
The Fellowship programme is founded on a partnership between the deanery, the Business School, and the local education providers. At its core, therefore, are relationships between ‘traditionally disparate’ worlds (Playdon, Shaw and Penlington, 2009) and the Deanery sees its role as creating a sense of identity for the partnership and in building a ‘community of practice’. The intention is that all participants should develop a shared language, and, thus, mutual understanding, and through that, to learn from each other. It is this commissioning, brokering, mediating role which has required the Deanery to spend time in communicating and building relationships – in inviting involvement and dialogue and in providing opportunities and mechanisms for this community to develop – and there is evidence of considerable efforts to build a Course Team and a sense of potency amongst the participants. The Heads of the School of Leadership comment on the fundamental importance of ‘building relationships’ and argue that it can only happen ‘when you’re in the same room together every now and then, talking about things.’ They have seen such conversations achieving immediate ‘shifts’ in ‘perceptions’ and thus learning. Successes: At least one Facilitator reports a developing relationship with the Deanery as a positive aspect of the programme. Closer links between the Deanery, local education providers and Brighton Business School have been fostered by the programme. Fellows have derived much support from one another and have valued the guidance and input of their peers. Issues and challenges: Some Facilitators have been absent from meetings with the Deanery and the MSc Course Leader about the programme and have not had the opportunity to learn from their colleagues and to share their experiences. MSc module leaders and other academic tutors have not attended meetings with the Deanery and Leadership Facilitators, lessening their connection to the different aspects of the programme. Most of the Fellows feel less connected to the Deanery than they do to the other partners. The successes of the Fellows and their contributions to their organisations have not always been captured. Similarly their specific development needs have not always been articulated.
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KSS School of Clinical Leadership Fellowship Evaluation Sustaining the impetus provided by the programme and continuing the Fellows’ leadership development would enhance return on the investment in their learning and perpetuate the learning network. Recommendations: Cultivate a relationship between the Deanery and the Fellows which positions the Deanery more as a source of learning than as a broker in cases of difficulty. The Deanery’s facilitation of any future action learning sets might help to achieve this. Ensure that feedback is at the heart of the programme – with Facilitators providing regular feedback to their Fellows and, at the end of the programme, specific comment about the Fellows’ contributions to their organisations, which is then publicised more widely. In addition to this, academic staff, the Deanery and Facilitators together to discuss the collective learning needs of the Fellows and, as far as is possible and viable, the specific needs of individual Fellows, at points throughout the programme. Invite all the Fellows to the occasional joint meeting with the Leadership Facilitators and Deanery to promote a sense of partnership and of participation in the wider Course Team. Use the meeting to explore progress and as a source of feedback about the programme and its organisation. Establish some forum to encourage Fellows to report back and share their insights regularly in the future. Their involvement in, or facilitation of, action learning sets with the new Fellows, and, in time, with other alumni, might be a productive way of capitalising on their learning and enhancing it in the future – and helping to build a community of practice.
6. Overall Satisfaction
There is universal satisfaction with the programme – by both Facilitators and Fellows – although certain components receive more positive feedback than others, with the guidance and teaching input on the academic course and the exposure and access to senior management being rated particularly highly in relation to the Fellows’ learning and development. None of the risks identified in the business case have materialised: trainees have shown interest, the four extra posts have allowed the programme to be educationally effective and more cost-effective, the Masters has been validated and delivered within the timescale, the
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KSS School of Clinical Leadership Fellowship Evaluation local education providers have received the trainees, and, in all cases, supervision has been provided and suitable projects found. The recruitment of senior registrars has been welcomed by both the workplace mentors and the Fellows themselves as being an appropriate stage at which to participate in such a programme. The recruitment of Fellows immediately on completion of their GP training is viewed less positively, with some concerns about the application of their learning at this point in their careers and the impact on their clinical practice. Nevertheless, the inclusion of this group continues to be seen as important, and increasingly so, despite the inherent difficulties. The design of the programme has been commended: the combination of a full-time Masters programme and work placements with formalised facilitator roles for senior managers is deemed an effective model by all participants and contributors to the programme. The marriage between academic and practitioner perspectives has been achieved to a large extent, and a learning community has been created, although there remain areas where common understanding is yet to be developed. Fuller participation by some individuals from each set of participants – Fellows, Facilitators and academic tutors – would benefit this community and enhance learning. The Deanery has played a significant role in facilitating relationships and has demonstrated considerable capacity to engage in dialogue with, and to learn from, the different participants, continually monitoring its own performance and contributions with a view to improving the programme for future iterations.
7. Learning and Outcomes
The criteria for success identified by the different players at the start of the programme have largely been met. These included good completion rates, educational and clinical effectiveness, positive impacts on work organisations and changes in the clinical setting as a result of the programme, the creation of ‘new ways of being’ in the Fellows, the development of Fellows’ confidence and their increased understanding of ‘the system’, and a desire that they will ‘go on to be effective leaders over and above their peers’. This latter is a longer-term goal but there is evidence that the other objectives have already been achieved. The programme has led to substantial individual learning by the Fellows (in terms of knowledge, skills and attitudes) which will be applied in the future as Fellows help to drive through change in their clinical teams and, in time, take on formal leadership responsibilities. There has also been significant organisational learning for the local education providers with some evidence of improved patient outcomes.
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7.1 Individual learning achieved:
Formal confirmation that Fellows have met the programme’s desired learning outcomes through the award of a Fellowship Certificate and an MSc Management. At the time of writing, all Fellows are on track to achieve both awards. A reported growth in Fellows’ self-awareness and personal skills. Increased understanding by the Fellows of the NHS, its component organisations and non-clinical aspects – again reported by both Fellows and their Facilitators. Increased understanding by Fellows of services outside their own specialities. Shifts in Fellows’ beliefs about leadership and change, with a new recognition of the complexity of the NHS and of the obstacles and difficulties involved in achieving change – accompanied by a heightened appreciation of the need for clinicians and managers to work together. Increases in management and leadership understanding and capability reported by Fellows themselves and by their Facilitators, with possession of new insights and awareness, a battery of tools and models, and knowledge of information sources, resources and processes. Full competence will take time to achieve and requires Fellows to acquire more experience: the Fellowship has, however, provided a sound foundation. Increased understanding by Facilitators of the leadership development needs of clinicians.
7.2 Application of learning:
Engaging other doctors in leadership: Some Fellows have already had a direct impact in terms of shifting others’ perceptions of the relationship between clinical practice and leadership, (reported by both Fellows and Leadership Facilitators.) The Fellows see themselves as being in a unique position to communicate to their clinical colleagues in the future and are keen to ‘spread the word.’ Taking on leadership roles: Whilst few of the Fellows will immediately take on a formal ‘designated’ leadership position, they will be able to apply their learning in their clinical roles and will be bringing a new perspective and a willingness to drive change.
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KSS School of Clinical Leadership Fellowship Evaluation
7.3 Organisational learning and impact:
Contributing to the development of partnerships and networks: A number of Fellows have had inputs into the development of partnerships, particularly in terms of highlighting the issues and obstacles, and in increasing their organisation’s understanding of the processes involved in building networks and relationships with other organisations/units. Providing new insights and perspectives: Fellows have provided their work placement organisations with a ‘fresh pair of eyes’ and have offered new insights. Particular value has been derived from the Fellows’ approach to researching issues and organisational problems for their Masters assignments. In carrying out their investigations they have raised questions which have been a source of learning for their organisations, and, in some cases, they have contributed to problem resolution as a result of the implementation of their recommendations. Contributing to change: There are examples of Fellows who have sown the seeds of change through highlighting examples of good practice, encouraging collaboration and communication, and helping their colleagues to see connections between previously seemingly disparate areas of work. Impacting on patient and service outcomes: It is too early to make many claims about the programme’s contributions to patient and service outcomes but there is evidence of impact as a result of the Fellows’ involvement. Two Facilitators explicitly claim that the Fellowship has resulted in improved patient outcomes, one citing specific projects. Two Fellows mention improvements – in pathways of patient care and in patient safety – while others assert that the implementation of their recommendations will bring measurable improvements but that it is too soon to measure the outcomes.
8. The Business Case
KSS Deanery’s Leadership Fellowship programme has made a contribution to the Strategic Health Authority’s strategic aim to build a pool of ‘excellent’ clinical leaders, with increases in the Fellows’ leadership capability reported by Fellows and their Facilitators. It has raised the profile of clinical leadership and has helped to engage a wider audience, while contributing to workforce development – of the Fellows’ themselves and of others who have been involved in the programme. The business case originally set out for the programme has been
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KSS School of Clinical Leadership Fellowship Evaluation achieved, with some, if limited, evidence already of improvements in patient outcomes as a result of participation in the programme. The potential for future impact is considerable, as a consequence of the implementation of the Fellows’ recommendations and service improvement plans, through their continuing contribution to the development of their services, and as a result of the wider organisational learning achieved through their insights. This longer-term impact will be heightened if the Fellows can sustain their motivation and learning, if there is continuing investment in their development and if they find employment in organisations whose cultures encourage those with leadership capability.
9. Lessons from KSS Deanery’s Clinical Leadership Fellowship Programme
KSS Deanery’s Fellowship programme is founded on fostering relationships and on providing opportunities for dialogue. Whilst it is about developing leadership capability in specific individuals, it is also about sowing the seeds of change in groups and organisations and about building connections and impacting on the wider community and the worlds in which the participants interact. The delivery of the programme has itself brought together the workplace and academia and every effort has been made to ensure that the one world informs the other. Lessons about how these two can be brought even more closely together have emerged in this first iteration of the Fellowship, as has learning about the meaning and manifestations of clinical leadership and how to nurture it. Giving the participants opportunities to experience ambiguity and complexity in a clinical setting and to examine these experiences in conjunction with senior managers who are genuinely interested in the learners’ perspectives whilst also offering insights in return – an approach which values mutual learning – is of prime importance. Also fundamental is the development of a selfquestioning, critical and reflective approach which is exercised and practised both in the classroom and in the workplace. If the intervention also generates a willingness to struggle to achieve change and a determination to keep the patient at the forefront, then it can be deemed a success and its impact will emerge over time and extend beyond the life of the programme. Embedding this mindset depends not only on the careful selection of suitably motivated trainees but also on the ability and desire of the various contributors – facilitators, academic tutors and Deanery representatives – to model appropriate behaviours and attitudes and to inspire the participants to want to act. As one of the Fellow comments, acknowledging the need for a longer-term perspective and displaying the desire to use their learning and capability for patient benefit, the success of the programme can only ultimately be measured by ‘whether in my lifetime career in clinical service, I feel (and can demonstrate) that it has enabled me to help provide better patient care’.
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KSS School of Clinical Leadership Fellowship Evaluation
Summary Report: Independent External Evaluation of KSS Deanery’s Leadership Fellowship Programme
Sue Miller & Dr Sue Balint, August 2010
University of Westminster 35 Marylebone Road London NW1 5LS 020 7911 5000
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KSS School of Clinical Leadership Fellowship Evaluation
Executive Summary
KSS Deanery’s Clinical Leadership Fellowship programme commenced in September 2009. Eight specialist registrars began a one-year full-time Leadership Programme, combining a Masters degree, delivered by Brighton Business School, with a placement in a service unit. In January 2010, a team from Westminster Business School, University of Westminster, were commissioned to carry out an independent evaluation of the Fellowship. Their brief was to examine the experiences of the Fellows, those managing and delivering the programme in the Deanery and at Brighton, and the senior management mentors facilitating the work placements. The evaluators were also required to consider how far elements of the business case put forward in support of funding for the programme had been achieved. The evaluation team used various methods: a review of documentation, on-line questionnaires for completion by Fellows and by their designated mentors, focus groups, interviews and observations of meetings. The programme is distinctive in that it includes both primary and secondary care, uses comentors, ‘Leadership Facilitators’, in the workplace, and involves a management qualification at Masters level tailored specifically to clinical leaders. The decision to recruit senior registrars and to require them to complete a full-time, one year programme, without clinical responsibilities, also represents a different approach from that adopted by other Deaneries in their response to the Lord Darzi’s Next Stage Review (Department of Health, 2008). Generally, the design of the programme has been commended: the combination of a fulltime Masters programme and work placements with formalised facilitator roles for senior managers is deemed an effective model by all participants and contributors to the programme. A marriage between academic and practitioner perspectives has been achieved to a large extent and a learning community has been created, although there remain areas where a common understanding is yet fully to be developed. Whilst, initially, there was some lack of clarity and understanding about roles, responsibilities and the interplay between the academic programme and the workplace, the Deanery has played a very significant facilitating role in overcoming uncertainties. Whilst KSS Deanery’s programme is about developing leadership capability in specific individuals, it is also about sowing the seeds of change in groups and organisations and about building connections and impacting on the wider community and the worlds in which the participants interact and this has informed the approach. The programme has, therefore, been founded on fostering relationships and providing opportunities for dialogue.
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KSS School of Clinical Leadership Fellowship Evaluation The criteria for success identified by the different players at the start of the programme have largely been met. These included good completion rates, educational and clinical effectiveness, positive impacts on work organisations and changes in the clinical setting as a result of the programme, the creation of ‘new ways of being’ in the Fellows, the development of Fellows’ confidence and their increased understanding of ‘the system’, and a desire that they will ‘go on to be effective leaders over and above their peers’. This latter is a longer-term goal but there is evidence that the other objectives have already been achieved. Lessons have emerged from this first iteration of the Fellowship. Giving the participants opportunities to experience ambiguity and complexity in a clinical setting and to examine these experiences in conjunction with senior managers who are genuinely interested in the learners’ perspectives and offer their own insights in return – an approach which values mutual learning – is of prime importance. Also fundamental is the development of a selfquestioning, critical and reflective approach which is practised and exercised both in the classroom and the workplace. Generating a willingness to struggle to achieve change and a determination to keep the patient at the forefront is also important, though difficult to ‘design’ into the programme. Embedding this mindset depends not only on the careful selection of suitably motivated trainees, but also on the ability and desire of the various contributors – facilitators, academic tutors and Deanery representatives – to model appropriate behaviours and attitudes and to inspire the participants to want to act. KSS Deanery’s Leadership Fellowship programme has made a contribution to the Strategic Health Authority’s strategic aim to build a pool of ‘excellent’ clinical leaders, with increases in the Fellows’ leadership capability reported by Fellows and their Facilitators. It has helped to raise the profile of clinical leadership and to engage a wider audience, while contributing to workforce development – of the Fellows’ themselves and of others who have been involved in the programme. Elements of the business case originally set out for the programme have, therefore, been achieved with some, if limited, evidence already of improvements in patient outcomes as a result of participation in the programme. The potential for future impact is considerable, as a consequence of the implementation of the Fellows’ recommendations and service improvement plans, through their continuing contribution to the development of their services, and as a result of the wider organisational learning achieved through their insights. This longer-term impact will be heightened if the Fellows can sustain their motivation and learning, if there is continuing investment in their development and if they find employment in organisations whose cultures encourage the deployment of leadership capability.
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KSS School of Clinical Leadership Fellowship Evaluation
Summary Report
1. Background and impetus for the Fellowship programme
The Darzi Report highlighted the failure to develop competent clinical leaders across the NHS, and emphasised their vital importance in the transformation of services, and in the enhancement of the patient experience and patient outcomes. KSS Deanery was required to respond to this report which proposed the establishment of Clinical Leadership Fellowships (paragraph 34 ‘Next Stage Review: High Quality Care for All’) and was keen to do so. Both the Dean Director and the Deputy Dean Director/GP Dean were already demonstrating a commitment to expanding leadership education for clinicians, and the Fellowships were one of the strands agreed as part of the establishment of a KSS School of Clinical Leadership in October 2008. The subsequent expansion of the number of Fellows (for educational reasons) – from four to eight – led to a requirement for additional MPET funding, specifically for additional Fellowships, and a business case to extend the Fellowship programme was approved in February 2009. The key drivers remained those identified in the business case set out and approved for the setting up of a School of Leadership. The KSS Fellowship can, therefore, be seen in the context of a bigger strategy to improve and expand clinical leadership education which is being embraced by the Deanery. The business case for the establishment of the new School of Leadership cites a range of potential outcomes – improving patient safety, improving the patient experience, service improvement, leadership, workforce planning, strategy and development – and, by implication, it is hoped that the Fellowship will ultimately contribute to these. It is, however, recognised by those involved in the programme that finding evidence to prove a link between the Fellowship and these outcomes is not straightforward and it may take time to emerge.
2. The programme’s components
Eight specialist registrars commenced a one-year full-time Leadership Programme in September 2009, combining a Master’s degree with a placement in a service unit. The programme is distinctive in several respects: the involvement of both primary and secondary care, the use of co-mentors, ‘Leadership Facilitators’, in the workplace, and the inclusion of a management qualification at Masters level tailored to the learning needs of clinicians. The decision to recruit senior registrars, i.e. doctors at a relatively early stage in their careers, and GPs immediately following training, was founded on a belief that those who are interested in management and leadership should be given ‘a genuine opportunity.....earlier in the cycle’ (Dean Director). Also a significant part of the approach is the employment status and length
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KSS School of Clinical Leadership Fellowship Evaluation of the programme with the Fellows completing a full-time one year programme, without any clinical responsibilities. The reasoning is that this is the most viable arrangement both for the host Trust and the Fellow.
3. Underlying philosophy of learning and of leadership
Fundamental to the programme is the relationship between the academic aspects of the programme and the workplace element. The Fellowship is founded on a particular view of education and learning: ‘learning...taking place in the real life, complex, problematic, messy workplace, rather than simply in....a kind of ivory tower academy...’ (Head of Education) The desire to bind together ‘practice and the academy’ has informed the programme, with the appointment of leadership facilitators and a conscious emphasis on getting ‘the workplace completely united with the University.’ The relationships involved in learning are also given a prime place in the Deanery’s approach. Allied to the approach to education is the conception of leadership. This is expressed in different ways by the key architects of the programme – the Deans and Heads of Education in the Deanery. The GP Dean expresses a requirement for the academic programme to provide a systematic approach ‘to management in addition to leadership’, but with clinical/patient benefit being the ultimate goal - ‘a clinical leader is someone who can motivate others to make change for clinical benefit, for patient benefit.’ (GP Dean) The Head and Deputy Head of Education also share a particular concern to explore the meanings of leadership and management in the context of a clinical environment but express it in this way: ‘In this environment, the relationship needed to be reversed... the larger term is leadership......Leadership is the hard skills; the small term is management......’ These positions have informed the design of the programme.
4. Independent External Evaluation
4.1 Evaluation brief
KSS Deanery commissioned an independent evaluation of the programme in January 2010, with a brief to focus particularly on the following: The organisation of the programme and the business and educational infrastructures supporting it The experience of the full-time Clinical Leadership Fellows participating in the programme
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KSS School of Clinical Leadership Fellowship Evaluation The experience of the Course Team – i.e. the academic staff providing the programme and the ‘Leadership Facilitators’ (senior managers from the local education providers who facilitate the Fellows’ learning within the workplace) The experience of the Academic and Clinical Heads of the School of Leadership The achievement of elements of the business case (which was identified in support of the establishment of a School of Leadership within the Deanery) Information and perceptions were sought about the programme as follows: Context - the circumstances under which the programme was brought into being; why it is being funded; the expectations of the various stakeholders Administration – the recruitment and selection of learners; the organisation and usefulness of the briefing, support and follow up arrangements Processes – the feelings of the participants about the learning process; what they thought they were learning and how they were learning; the meaning the various events and elements had for the participants; the perceptions of all those involved Inputs - the design, planning and delivery of the programme Outputs – changes in the learners; organisational outcomes; unintended outcomes
4.2 Methods
A range of methods were used to evaluate the programme: Review of programme documentation (February 2010) Observation of a planned meeting of Leadership Facilitators (March 2010) Interviews with key members of the Deanery – Dean Director, Deputy Dean Director/GP Dean, Head of Education, Deputy Head of Education, Clinical Head of School of Leadership, Academic Head of School of Leadership – to identify how different key players view the programme, their role in its genesis and delivery, and how they visualise success. (April 2010) Online questionnaires issued to all Clinical Fellows – to explore their experiences and the learning they have achieved, and to highlight their perceptions of the contribution of different elements of the programme (April 2010) Interview with the MSc Course Leader (May 2010) Facilitation of a focus group comprising the Clinical Fellows (May 2010) Online questionnaires issued to all Leadership Facilitators – to explore their perceptions of the organisation and administration of the programme, their own
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KSS School of Clinical Leadership Fellowship Evaluation roles and contributions, and the perceived impact of the programme on their Fellows and their service units (June 2010) Facilitation of a focus group comprising Leadership Facilitators (June 2010) Telephone interview with a Leadership Facilitator (July 2010) Attendance at Fellows’ session at the Deanery’s leadership conference – ‘Are all doctors leaders?’ (July 2010)
5. Findings and recommendations
Summaries of the key themes which emerged in the qualitative analysis are provided below in relation to each aspect of the programme, with accompanying recommendations.
5. 1 Organisation and administration
The genesis of the Fellowship reflects its place as part of a larger leadership strategy and set of developments within the Deanery. The programme was developed over time as new appointments were made and new structures were put in place. Attention was given initially to the academic aspects and the Fellows were recruited before the flesh was put on the bones of the arrangements. This meant that work was done ‘retrospectively’, some immediately prior to the start of the programme, in helping Fellows to understand what would be involved in undertaking the Fellowship and in clarifying roles for the Facilitators. Successes: The selection process has resulted in high calibre, self-motivated Fellows. The Deanery has responded to Facilitators’ concerns and uncertainties throughout and has provided ongoing opportunities for dialogue and discussion about the organisation and operation of the programme. Issues and areas of challenge: Application process – the organisation of the academic course and timetable for it was not clearly explained in the initial briefing documentation. Briefing of Leadership Facilitators – the Facilitators were not wholly clear about their roles and the importance and requirements of the Masters programme at the beginning of the programme (although this understanding developed over time.) Induction in the workplace - there was some variation in the quality of induction, with some Fellows being given insufficient orientation when they first embarked on their work placement. Organisation of action learning sets – a lack of fixed arrangements impacted on the Fellows’ commitment to these.
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KSS School of Clinical Leadership Fellowship Evaluation Recommendations: Ensure that the timetable for the academic programme is well-communicated in the recruitment literature. Deanery to set minimum requirements for workplace induction with suggestions regarding an appropriate process - in terms of briefings, introductions to key personnel and physical provision (desk, telephone etc.) Schedule and communicate dates for meetings of action learning sets at the beginning of the programme.
5.2 The Academic Course
All Fellows are working towards an MSc Management (Leadership for Clinicians) which is delivered by Brighton Business School and led by an MSc Course Leader. The inclusion of a management qualification at Masters level was deemed a fundamental, and unique, part of the approach to the Darzi initiative by KSS Deanery, by desire specifically of the Head and Deputy Head of Education. The course involves a series of modules, all of which (in their entirety) are specific to this programme, but a number involving teaching of the Fellows alongside some of Brighton’s MBA Public Services students. The Fellows complete different assessments from their MBA counterparts and have an additional day of input. Other modules are taught exclusively to the Fellows, two by staff from the Deanery – namely ‘Leadership & Ethics’ and ‘Organisational Learning & Leadership’. The decision to expand the number of Fellows to eight was a result of the need to ensure that the delivery of such modules was educationally viable. Each module requires completion of a project, drawing on research and experience in the workplace, and a reflective statement – with a final larger integrative project. Successes: The academic course has been well-received by Fellows and Facilitators. The course content, tutor input and the guidance given by the Course Leader have all been rated very positively. The assessment requirements of the academic programme have been an effective vehicle for ensuring that Fellows explore different aspects of organisation and management and have required them to gather and examine evidence. Fellows have achieved significant learning from the academic course and it has offered them concepts and tools which they can apply in the workplace (see further below, in discussing impact.)
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KSS School of Clinical Leadership Fellowship Evaluation The difference in approach between the Business School and the ‘Deanery modules’ has enhanced the Fellows’ academic experience, although requiring acclimatisation to different ‘languages’ and styles of teaching and learning. The course has helped Fellows to recognise the fact that management and leadership is not about ‘right answers’ but about coping with ambiguity and complexity. Issues and challenges: The Leadership Facilitators would have valued more detail about the content of the academic programme and its requirements in terms of projects and assignments. Completing academic assignments alongside other demands has been challenging for most of the Fellows. It has been difficult for Fellows and their Facilitators to find an effective balance between the different elements of the programme to prevent the Masters from overshadowing other aspects of the workplace component. There has been some reluctance by the Fellows to use practitioner research for their academic assignments: the Deanery is conscious that they could expand their learning opportunities by adopting this approach. Fellows are unfamiliar with the academic literature around leadership and would have appreciated more background and formal input before exploring ethical issues. Fellows see the academic course as being more about ‘management’ than ‘leadership’, with their leadership learning largely taking place in the workplace. How far this is an issue is worthy of further exploration and discussion. Recommendations: Ensure that Fellows are fully aware of the pressures, time commitment and challenges involved in pursuing the MSc alongside involving themselves fully in their work placements. Provide a mechanism in addition to formal meetings for informing Facilitators about the content of the academic programme and accompanying assignment requirements. Expand the meaning of ‘research’ in the minds of the Fellows through an extended session on research strategies and methodologies. Establish the prior knowledge of the Fellows before they start the formal programme, and provide background information and required reading before they enrol.
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KSS School of Clinical Leadership Fellowship Evaluation
5.3 The Workplace Component
Brighton Business School has long been using work-based projects and completion of these academic assignments requires an organisation on which to draw. This approach accords with the Deanery’s concern to ensure that there is a unity between the academic and praxis and the requirement to offer a Fellowship which allows the development of leadership attitudes and behaviours. Thus all Fellows have a placement with a local education provider (LEP). Four of the seven Fellows, (the eighth Fellow has been absent on maternity leave for much of the programme), are in secondary care, with the remaining three attached to a PCT. In designing the programme it was recognised that Fellows would need support in the workplace in order to negotiate access and to provide a sounding-board, hence the appointment of ‘Leadership Facilitators’. It was also acknowledged that this person needed to be someone who was well-respected and relatively senior, as has been the case in each LEP. There have been varying interpretations of the role of the workplace component, with some - Fellows and Facilitators - seeing it mainly as a source of projects for the Masters programme and with Fellows being allocated (or finding) tasks accordingly. For others, there is a wider interpretation of the contribution of the work placement – with Fellows having involvement outside their Masters’ projects and assignments. This latter approach is one which the Deanery welcomes. The degree to which Fellows are required to find and/or delineate their own projects also varies as does the way in which the different Facilitators have perceived their roles and contributed to the programme (to be discussed further in a separate section of the report below.) Successes: There were a number of examples of involvement by Fellows in teams and activities across the organisation – outside the requirements of the academic programme. These Fellows have participated more completely and contributed to a range of work streams as a consequence of this involvement. All Fellows have had exposure to the wider workings of the NHS and to previously unfamiliar aspects of organisational life. Meetings organised by the Deanery and involving the academic Course Leader and the Facilitators have brought the workplace and the academic components closer together. Experiences in the workplace have reinforced learning from the course that leadership requires a different mindset from that engendered by clinical training.
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KSS School of Clinical Leadership Fellowship Evaluation Issues and challenges: There has been significant variation in the level of integration and involvement of the Fellows and in their degree of exposure to different aspects of organisation: a difference between those in PCTs and others in hospitals was evident, with the former having fewer opportunities to become involved. The PCT Fellows, to some extent, were perceived by others, and perceived themselves, to be observers rather than participants. It has been difficult to achieve a wholly common understanding about the role of the workplace and its relationship with the academic programme. Whilst discussions between the Course Leader and Facilitators have assisted in this, a lack of full attendance by Facilitators and a lack of connection to all elements of the programme by the academic tutors at Brighton mean that the different parties are not fully cognisant of each other’s approach and perspectives. Recommendations: Define the relationship between the workplace and the academic programme for Fellows and Facilitators and encourage both parties to see the work placement as more than a source of academic assignments. Encourage academic tutors and Leadership Facilitators to communicate with one another, and emphasise the value to Facilitators of attending some of the teaching. A possible approach might be to build the occasional joint session into the teaching programme or to involve the Facilitators in asking questions and providing feedback on an ‘in-class’ case study presentation by Fellows as part of the academic course. Incorporate some joint projects between Fellows in primary and secondary care to ensure that they have exposure to a range of contexts and to build partnerships. Monitor the work experiences of primary care Fellows and seek ongoing feedback from their Facilitators to ensure that the Fellows are being made aware of how they can apply their leadership skills in different settings and contexts and feel confident and equipped to do so.
5.4 The Role of the Leadership Facilitators
The Deanery’s model of ‘Partnership in Practice’ with its emphasis on ‘collaborative, participative....working relationships’ and its concerns to unite the University with the workplace mean that the ‘leadership facilitators’ are seen as ‘an absolutely crucial part of the development of the programme.’ (Head of Education). The School conceives these leadership facilitators as quite distinct from mentors, in that ‘the role of the facilitator wasn’t
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KSS School of Clinical Leadership Fellowship Evaluation to tell people what to think or how to think.....’ Instead they are there ‘to open doors, to provide access....to facilitate.’ Embedded in this is the notion of mutuality – the leadership facilitator component of the Fellowship is described as ‘a co-mentoring programme’, (Head of Education), with the implication that there will be mutual learning, with an emphatic requirement that Fellows are not simply to be ‘done to’ but are actively involved in exploring possibilities, opportunities and meanings with their facilitators, who themselves need to develop in their roles: the Deanery is not only teaching a Masters programme but ‘we’re also actually teaching, informally, a leadership facilitator programme.’ (Deputy Head of Education). Successes: All Facilitators have contributed to their Fellows’ learning, playing a variety of roles. There are some examples of outstanding support and mutual learning. Acting as a Leadership Facilitator has been a source of satisfaction and of valuable insights for a number of those who have taken on the role. Issues and challenges: For some Facilitators, their contribution to the programme is to some extent compromised by their lack of time and availability. The relationship between some Fellows and their Facilitators, whilst making an important contribution, could be more facilitative. Recommendation: Specify the role of the Facilitator and make expectations explicit and specific regarding time commitment and involvement. Communicate these at an early stage.
5.5 The Deanery and the Fellowship: the Leadership Portfolio
A further component of the programme is a portfolio which records the Fellows’ learning and development over the period of the Fellowship. Students have been required to self-assess themselves against the KSS Standards for Leadership at the beginning of the programme, and then to revisit these to document their progress throughout. (It should be noted that the nature of these standards and assessment against them is outside the scope of the evaluation.)
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KSS School of Clinical Leadership Fellowship Evaluation Fellows are expected to keep a learning log recording their activities, achievements and reflections and it is hoped that they will discuss these with their Leadership Facilitators. A successfully completed portfolio and associated viva, (conducted by the Head of Leadership and one of the Facilitators), where each Fellow presents their achievements in person, results in a Certificate of Completion of the Leadership Fellowship, which can be awarded regardless of success or otherwise on the Masters programme. Successes: The portfolio has provided a vehicle for provoking reflection and for prompting conversations about development. Issues and challenges: Both Fellows and Facilitators find the language and paperwork involved in the portfolio cumbersome. There is some lack of understanding about what is required and how to go about making best use of the portfolio. There are concerns by Fellows about confidentiality, meaning that they feel inhibited about recording all their reflections. Some Fellows have found it difficult to rate themselves and thus to track their progress. Recommendations: Where possible and appropriate, simplify the format and the language of the portfolio, using examples to demonstrate the relevance of the different competences and to enable Fellows and Facilitators to get behind the language. Reassure Fellows that records of learning will remain confidential. Discuss the portfolio on the MSc course, as well as in the workplace and at the Deanery, both to ensure that it assumes more importance and to heighten the interplay between the academic and workplace components, with the ‘practical’ aspects of leadership being given some exposure in the academic context. This would develop further the Fellows’ understanding of the relationship between leadership and management, and between practitioner and academic perspectives, and help them to make more sense of the practical implications of their learning.
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5.6 Action Learning Sets
One of the intended components of the programme was action learning. Two action learning sets were initiated, to be facilitated initially by the Course Leader at Brighton. These have rarely met and are thus reported by all parties as having made only a very limited contribution to the Fellows’ development. Two Fellows recognise the potential contribution of action learning sets and have expressed their disappointment. This disappointment is heightened by the fact that ‘the first one was really good’ – and it is acknowledged that it did achieve something: ‘I think it got us into a way of talking about stuff that we wouldn’t necessarily.’ There is a sense, however, in which the Fellows feel that they have become one informal action learning set. There is some debate in the School of Leadership about the purpose and continuing place of action learning sets in the Fellowship programme for the future – their possible contribution in bringing together clinicians from different services to develop partnerships is seen as a potentially significant benefit, particularly since this is something which could continue beyond the life of the programme. Successes: A number of Fellows found the initial meeting of their Action Learning Set very helpful. This initial meeting has spawned continued informal mutual learning amongst the Fellows. Issues and challenges: There is a lack of commitment by Fellows to formal, facilitated meetings.
Recommendation: Emphasise the value of action learning sets and their place in the programme by publishing a timetable for meetings in advance and building in a mechanism for ensuring that they are given time and attention by the Fellows – for example, an associated assessment, or a requirement for a record/observation or feedback by the Fellows on the process and the progress of their set.
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5.7 The Partnership
The Fellowship programme is founded on a partnership between the deanery, the Business School, and the local education providers. At its core, therefore, are relationships between ‘traditionally disparate’ worlds (Playdon, Shaw and Penlington, 2009) and the Deanery sees its role as creating a sense of identity for the partnership and in building a ‘community of practice’. The intention is that all participants should develop a shared language, and, thus, mutual understanding, and through that, to learn from each other. It is this commissioning, brokering, mediating role which has required the Deanery to spend time in communicating and building relationships – in inviting involvement and dialogue and in providing opportunities and mechanisms for this community to develop – and there is evidence of considerable efforts to build a Course Team and a sense of potency amongst the participants. The Heads of the School of Leadership comment on the fundamental importance of ‘building relationships’ and argue that it can only happen ‘when you’re in the same room together every now and then, talking about things.’ They have seen such conversations achieving immediate ‘shifts’ in ‘perceptions’ and thus learning. Successes: At least one Facilitator reports a developing relationship with the Deanery as a positive aspect of the programme. Closer links between the Deanery, local education providers and Brighton Business School have been fostered by the programme. Fellows have derived much support from one another and have valued the guidance and input of their peers. Issues and challenges: Some Facilitators have been absent from meetings with the Deanery and the MSc Course Leader about the programme and have not had the opportunity to learn from their colleagues and to share their experiences. MSc module leaders and other academic tutors have not attended meetings with the Deanery and Leadership Facilitators, lessening their connection to the different aspects of the programme. Most of the Fellows feel less connected to the Deanery than they do to the other partners. The successes of the Fellows and their contributions to their organisations have not always been captured. Similarly their specific development needs have not always been articulated.
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KSS School of Clinical Leadership Fellowship Evaluation Sustaining the impetus provided by the programme and continuing the Fellows’ leadership development would enhance return on the investment in their learning and perpetuate the learning network. Recommendations: Cultivate a relationship between the Deanery and the Fellows which positions the Deanery more as a source of learning than as a broker in cases of difficulty. The Deanery’s facilitation of any future action learning sets might help to achieve this. Ensure that feedback is at the heart of the programme – with Facilitators providing regular feedback to their Fellows and, at the end of the programme, specific comment about the Fellows’ contributions to their organisations, which is then publicised more widely. In addition to this, academic staff, the Deanery and Facilitators together to discuss the collective learning needs of the Fellows and, as far as is possible and viable, the specific needs of individual Fellows, at points throughout the programme. Invite all the Fellows to the occasional joint meeting with the Leadership Facilitators and Deanery to promote a sense of partnership and of participation in the wider Course Team. Use the meeting to explore progress and as a source of feedback about the programme and its organisation. Establish some forum to encourage Fellows to report back and share their insights regularly in the future. Their involvement in, or facilitation of, action learning sets with the new Fellows, and, in time, with other alumni, might be a productive way of capitalising on their learning and enhancing it in the future – and helping to build a community of practice.
6. Overall Satisfaction
There is universal satisfaction with the programme – by both Facilitators and Fellows – although certain components receive more positive feedback than others, with the guidance and teaching input on the academic course and the exposure and access to senior management being rated particularly highly in relation to the Fellows’ learning and development. None of the risks identified in the business case have materialised: trainees have shown interest, the four extra posts have allowed the programme to be educationally effective and more cost-effective, the Masters has been validated and delivered within the timescale, the
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KSS School of Clinical Leadership Fellowship Evaluation local education providers have received the trainees, and, in all cases, supervision has been provided and suitable projects found. The recruitment of senior registrars has been welcomed by both the workplace mentors and the Fellows themselves as being an appropriate stage at which to participate in such a programme. The recruitment of Fellows immediately on completion of their GP training is viewed less positively, with some concerns about the application of their learning at this point in their careers and the impact on their clinical practice. Nevertheless, the inclusion of this group continues to be seen as important, and increasingly so, despite the inherent difficulties. The design of the programme has been commended: the combination of a full-time Masters programme and work placements with formalised facilitator roles for senior managers is deemed an effective model by all participants and contributors to the programme. The marriage between academic and practitioner perspectives has been achieved to a large extent, and a learning community has been created, although there remain areas where common understanding is yet to be developed. Fuller participation by some individuals from each set of participants – Fellows, Facilitators and academic tutors – would benefit this community and enhance learning. The Deanery has played a significant role in facilitating relationships and has demonstrated considerable capacity to engage in dialogue with, and to learn from, the different participants, continually monitoring its own performance and contributions with a view to improving the programme for future iterations.
7. Learning and Outcomes
The criteria for success identified by the different players at the start of the programme have largely been met. These included good completion rates, educational and clinical effectiveness, positive impacts on work organisations and changes in the clinical setting as a result of the programme, the creation of ‘new ways of being’ in the Fellows, the development of Fellows’ confidence and their increased understanding of ‘the system’, and a desire that they will ‘go on to be effective leaders over and above their peers’. This latter is a longer-term goal but there is evidence that the other objectives have already been achieved. The programme has led to substantial individual learning by the Fellows (in terms of knowledge, skills and attitudes) which will be applied in the future as Fellows help to drive through change in their clinical teams and, in time, take on formal leadership responsibilities. There has also been significant organisational learning for the local education providers with some evidence of improved patient outcomes.
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7.1 Individual learning achieved:
Formal confirmation that Fellows have met the programme’s desired learning outcomes through the award of a Fellowship Certificate and an MSc Management. At the time of writing, all Fellows are on track to achieve both awards. A reported growth in Fellows’ self-awareness and personal skills. Increased understanding by the Fellows of the NHS, its component organisations and non-clinical aspects – again reported by both Fellows and their Facilitators. Increased understanding by Fellows of services outside their own specialities. Shifts in Fellows’ beliefs about leadership and change, with a new recognition of the complexity of the NHS and of the obstacles and difficulties involved in achieving change – accompanied by a heightened appreciation of the need for clinicians and managers to work together. Increases in management and leadership understanding and capability reported by Fellows themselves and by their Facilitators, with possession of new insights and awareness, a battery of tools and models, and knowledge of information sources, resources and processes. Full competence will take time to achieve and requires Fellows to acquire more experience: the Fellowship has, however, provided a sound foundation. Increased understanding by Facilitators of the leadership development needs of clinicians.
7.2 Application of learning:
Engaging other doctors in leadership: Some Fellows have already had a direct impact in terms of shifting others’ perceptions of the relationship between clinical practice and leadership, (reported by both Fellows and Leadership Facilitators.) The Fellows see themselves as being in a unique position to communicate to their clinical colleagues in the future and are keen to ‘spread the word.’ Taking on leadership roles: Whilst few of the Fellows will immediately take on a formal ‘designated’ leadership position, they will be able to apply their learning in their clinical roles and will be bringing a new perspective and a willingness to drive change.
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KSS School of Clinical Leadership Fellowship Evaluation
7.3 Organisational learning and impact:
Contributing to the development of partnerships and networks: A number of Fellows have had inputs into the development of partnerships, particularly in terms of highlighting the issues and obstacles, and in increasing their organisation’s understanding of the processes involved in building networks and relationships with other organisations/units. Providing new insights and perspectives: Fellows have provided their work placement organisations with a ‘fresh pair of eyes’ and have offered new insights. Particular value has been derived from the Fellows’ approach to researching issues and organisational problems for their Masters assignments. In carrying out their investigations they have raised questions which have been a source of learning for their organisations, and, in some cases, they have contributed to problem resolution as a result of the implementation of their recommendations. Contributing to change: There are examples of Fellows who have sown the seeds of change through highlighting examples of good practice, encouraging collaboration and communication, and helping their colleagues to see connections between previously seemingly disparate areas of work. Impacting on patient and service outcomes: It is too early to make many claims about the programme’s contributions to patient and service outcomes but there is evidence of impact as a result of the Fellows’ involvement. Two Facilitators explicitly claim that the Fellowship has resulted in improved patient outcomes, one citing specific projects. Two Fellows mention improvements – in pathways of patient care and in patient safety – while others assert that the implementation of their recommendations will bring measurable improvements but that it is too soon to measure the outcomes.
8. The Business Case
KSS Deanery’s Leadership Fellowship programme has made a contribution to the Strategic Health Authority’s strategic aim to build a pool of ‘excellent’ clinical leaders, with increases in the Fellows’ leadership capability reported by Fellows and their Facilitators. It has raised the profile of clinical leadership and has helped to engage a wider audience, while contributing to workforce development – of the Fellows’ themselves and of others who have been involved in the programme. The business case originally set out for the programme has been
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KSS School of Clinical Leadership Fellowship Evaluation achieved, with some, if limited, evidence already of improvements in patient outcomes as a result of participation in the programme. The potential for future impact is considerable, as a consequence of the implementation of the Fellows’ recommendations and service improvement plans, through their continuing contribution to the development of their services, and as a result of the wider organisational learning achieved through their insights. This longer-term impact will be heightened if the Fellows can sustain their motivation and learning, if there is continuing investment in their development and if they find employment in organisations whose cultures encourage those with leadership capability.
9. Lessons from KSS Deanery’s Clinical Leadership Fellowship Programme
KSS Deanery’s Fellowship programme is founded on fostering relationships and on providing opportunities for dialogue. Whilst it is about developing leadership capability in specific individuals, it is also about sowing the seeds of change in groups and organisations and about building connections and impacting on the wider community and the worlds in which the participants interact. The delivery of the programme has itself brought together the workplace and academia and every effort has been made to ensure that the one world informs the other. Lessons about how these two can be brought even more closely together have emerged in this first iteration of the Fellowship, as has learning about the meaning and manifestations of clinical leadership and how to nurture it. Giving the participants opportunities to experience ambiguity and complexity in a clinical setting and to examine these experiences in conjunction with senior managers who are genuinely interested in the learners’ perspectives whilst also offering insights in return – an approach which values mutual learning – is of prime importance. Also fundamental is the development of a selfquestioning, critical and reflective approach which is exercised and practised both in the classroom and in the workplace. If the intervention also generates a willingness to struggle to achieve change and a determination to keep the patient at the forefront, then it can be deemed a success and its impact will emerge over time and extend beyond the life of the programme. Embedding this mindset depends not only on the careful selection of suitably motivated trainees but also on the ability and desire of the various contributors – facilitators, academic tutors and Deanery representatives – to model appropriate behaviours and attitudes and to inspire the participants to want to act. As one of the Fellow comments, acknowledging the need for a longer-term perspective and displaying the desire to use their learning and capability for patient benefit, the success of the programme can only ultimately be measured by ‘whether in my lifetime career in clinical service, I feel (and can demonstrate) that it has enabled me to help provide better patient care’.
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