The Cardiologist’s tale: an inside account of change leadership David A Buchanan
Acknowledgements The research underpinning this case study was funded by a grant from The Thurnham Legacy, administered by Cranfield University School of Management. As well as expressing gratitude for that funding, the author thanks the consultant cardiologist on whom this case is based, and the many other members of staff who contributed their time and shared their experiences of change, making this case account possible.
Orientation ‘It is not enough for a clinician to act as a practitioner in their own discipline. They must act as partners to their colleagues, accepting shared accountability for the service provided to their patients. They are also expected to offer leadership and to work with others to change systems when it is necessary for the benefit of patients’ (Academy of Medical Royal Colleges, 2010). This case records the experience of a consultant cardiologist who, as head of service, led a series of improvements to the Norwood Hospital cardiology department in 2011/12. The Cardiac Services Redesign Project produced benefits for patients, staff and the hospital as a whole, and the cardiologist won a national award. How did he achieve these successful outcomes?

Norwood was formed in 2006 by a merger of the city’s two hospitals, City North and West Suburbs. Norwood had 14,000 staff, and an annual income of £760 million, caring for a population of one million. Cardiac services were provided on both campuses. There were 12 consultant cardiologists, with a cardiac assessment team that included a specialist registrar and cardiac nurses. The service had 46 beds, four cardiac catheter laboratories, inpatient echocardiography facilities, two surgical theatres, and dedicated intensive care units. The service saw around 5,000 new patients a year, and had over 12,000 follow-ups. The service had a history of improvement and change predating the merger. Achievements in the first year of this project included:
• cath lab sessions produced twice as many angiograms as before;
• the number of cath lab sessions cancelled was reduced from 27 to 5 a year;
• length of stay for patients with acute coronary syndrome was reduced from 7 to 5 days;
• specialist nurses were empowered to make triage and transfer decisions;
• the number of inpatients getting an echocardiograph within 24 hours of referral rose from 68 per cent to 90 per cent at City North, and from 82 per cent to 94 per cent at West Suburbs.
How did you become a change leader? I joined West Suburbs in 1999 and was clinical lead from 2005 to 2006. When the hospitals merged, there was myself and the clinical lead at City North. We were interviewed for the post of head of cardiology in 2007, and I was appointed. I did that for five years, stepping down in 2012. My role involved introducing national guidelines into a general medical environment rather than a cardiology one. I was to facilitate the merger process for two to three years, and then develop the service.

Once we had relocated, and dealt with the personality issues, we looked at inefficiencies in the department, hence the Cardiac Services Redesign Project. We had a presentation from the emergency department (ED), who had done some work with the corporate transformation team. They were positive about it, so I put us forward as a department which could benefit from support. For me, it was a case of having formal administrative support to develop ideas. One of the problems was that, in addition to working as a clinician, I would be organising, going to meetings, taking on board ideas – but often being a bit ineffective in terms of finishing those tasks, partly because of time. And that’s what the project gave me. What problems did you want to solve? We had an inefficient service. We had sessions available, but the whole team weren’t available at the same times. You might have the nurses available but not the doctors and vice versa. You are in a perverse situation where waiting times are high, and you have to incentivise doctors and others to do an out-of-hours ‘initiative list’, to reduce the waiting list.

So we had the space and the people to do the procedures, but there was no coordination between the different groups. The system was organised around the doctors, not around the patient. It fitted with their timetables. When they turned up, things got done, and when they didn’t – they didn’t. The catheter list was supposed to start at nine, but they might arrive at quarter to ten because they had been in a meeting, or they dropped a child off at school. Nobody could do anything until they arrived. Lists were cancelled. The doctor was allowed, the day or the week before, to say, ‘I’m not here next Wednesday’. And a nurse would contact patients to say, ‘Sorry, we’ve had to cancel your procedure.’ This behaviour was unacceptable. But there was frustration that ‘we can’t do anything about it because they are consultants’. The non-medical staff were enthusiastic to put this right. I became their mouthpiece, sitting with colleagues and challenging their behaviour, gently. If you are going to challenge a consultant, your facts have to be watertight. As a group, they challenge the data; that’s what you are taught in medical school – is it credible, is it relevant? And if you say, ‘this is happening’, they say ‘I don’t believe the data’, ‘this wasn’t my patient’, ‘I wasn’t there’, ‘how did you collect the data?’ Finally, when you have worked through that, they’ll say, ‘that might be the case for ED, but not for us’.

The service redesign was about publishing the inefficiencies, and then the efficiencies as they developed. Because we had robust data, you could show it was getting better, and people were feeling better because they were doing their jobs better. The nurse turnaround time was getting better. The physiology was getting better. The number of unmanned sessions started to fall. Savings appeared. Productivity was rewarded. The harder we worked, the more we got. When I went back for resources, they’d say yes. I was able to go to staff and say, ‘Remember the last time we did this, we got that machine – we can get another one.’ Why did you accept this position?

The service is relatively young. I had seen very good practice at other hospitals. Norwood had a history of warring trusts, led by two senior consultants who didn’t get on, and their departments were kept separate, with suspicion on either side. It was by accident rather than design, but I found that, when I became clinical lead at West Suburbs, I achieved quite a lot within five years. The service was transformed. I enjoyed that power, being able to do that. Not power in being able to tell people what to do, but I enjoyed the interface with GPs and commissioners and trust executives saying, this is what we want to do. And the game you had to play to convince people of your service. I was driven by the fact that the service for patients could be better, and that one way of achieving that was for me to be involved. The only way to make it better was for it to be multidisciplinary rather than just the doctors changing the way they worked, or the nurses or whatever. It was critical that everybody came on board, and I felt that I was in as strong a position to do that as anybody else. I had a senior colleague, who I have a lot of respect for, but he is more distant and hierarchical. I know from the conversations that I’ve had with others that there is an element of fear towards him, which I thought would not be positive in encouraging change. I put myself forward because I thought I could do it, and do it well, and if you do it yourself, the service reflects your personality. I think I was well placed because I’ve done a lot of work in primary care setting up services and secondary care services. I have worked in tertiary care elsewhere. This role was to join primary, secondary and tertiary care across two trusts.

Clinical leads often underestimate the amount of time that the managerial stuff will take. I think that grinds down some clinical managers because they don’t have allocated, dedicated, protected time to deliver the role. Can you describe your management style? I have been on courses, but I haven’t had any formal management training. It was learning on the job. My style is quite democratic, and I’m inclusive, not just doctor-orientated from a team approach. The service that I developed at West Suburbs was working with the nurses, the physiologists, and the doctors. Although there is a professional gap between doctors and others, I try not to have a hierarchy. I don’t work well with that. I think that was advantageous. With the merger, I wasn’t just merging the doctors – I was merging the nurses and the physiologists. When I realised that the doctors could be a block, it was a strategic decision on my part to merge the technicians and the nursing staff, who I had more managerial clout with. Once those disciplines came together, it was a natural progression that the doctors – to varying degrees – would come in to line. The crux was putting in place a mechanism that allowed us to monitor everybody’s behaviour. We measured everything, from the time that the patient arrived – is the patient turning up at a responsible time, when they’re supposed to be here? The time for the nurse to assess the patient and sort out the investigations. The time for the porter to take the patient to where they are supposed to be. The time for the procedure, for the nurses to get the patient ready, and the doctor doing it and the aftercare. So we had all of that logged, and when I was confident it was accurate, we went public with the data. My weakness, which I’ve never got to grips with – I’m not good at confrontation. There were times when taking a sterner approach would have been quicker and more efficient.

But if I face an obstacle, I’ll often go round it in preference to trying to smash it. There are some who go for the hard line confrontation, but . . . it’s knowing when to fight the right battles. It hasn’t caused a problem to date, but if I was in higher management and there was a big problem that needed me to confront somebody direct – how good would I be at it? The thing that has fascinated me about the management process has been how much power a small group of difficult consultants can have in preventing change. It’s out of proportion to the power that they ought to be able to wield. When I was first appointed as a consultant, I thought that they were all honourable men and women with a vocation and patients came first. Over time I’ve realised that they’re human beings like everybody else, but sadly there maybe 20 to 25 per cent who are driven by other reasons – financial gain or self-interest. Most of the service operates on goodwill, the vocation, the honourable men and women, but I am alarmed at the proportion who I wouldn’t categorise in that regard. That frustrates me about management in the NHS because I think that if I were chief executive of a company and I had a difficult colleague, I’d simply arrange for them to leave. But we don’t have that in medicine. In some ways that’s helpful, but in some ways it’s not.

What challenges did you face? I knew that within the group of 12, there would be two or three who were under-performing. But I didn’t challenge them, at first. I just published the data so that every member of staff could see it. It was on a board. Everybody was emailed. We had a weekly report, published by the cath lab manager. I set up a weekly meeting with all the relevant staff; there was one medical representative but the others were from the supporting disciplines – reviewing the previous week’s work to say, this is what we did, and ask is the data we collected believable before it went public. We also organised the system six weeks in advance because if you are going to change clinics and book people in for procedures you needed a six-week time lag. People who are not performing or not turning up for their allocated sessions, the explanations they would give were, ‘I didn’t know about it’, or ‘I booked it off as leave, the secretary forgot to make a note’. We took that away by saying, ‘Look, six weeks in advance, you are now locked in to this activity, ok? And unless we have a request or evidence that activity is going ahead, and if you cancel that activity, unless it’s the death of a family member or something like that, it goes ahead and it’s your responsibility.’ Previously, the doctor would just tell the secretary or the nurse and they would fix it. Whereas we transferred the responsibility to the consultants saying, ‘look, you can still have the staff do this for you, but it’s up to you to organise it and get somebody else to cover’.

‘One minute they wanted to improve the performance of the cath labs and the next day they cancelled activity so that we could meet on a Monday morning. But this proved important as we wouldn’t have been able to achieve as much in such a space of time otherwise. Consultants, nurses, healthcare assistants, physiologists, ward staff and radiologists got involved and it has been really effective to make a decision together and then implement it.’ (Cath lab nurse) We said look, this is so important, we are cancelling the activity for the morning, and we want people to attend. I spoke to the line managers and said we must have everybody here because this is what we’re trying to do. And there was the usual row of consultants, arms folded, what’s this all about, and various ripples of enthusiasm as you worked your way back. There were eyes rolling as if to say, it’s all very well talking about this, but a lot of it isn’t achievable. We fed back on the project later, and even our consultant colleagues recognised that it had achieved something. But that was because we published their efficiency data, so it was also a reflection on them. It proved difficult to get the time for the weekly meeting, so I cancelled a quarter of one of my sessions so that the staff could be available to come along. It was a lab session, just an hour a week first thing on a Monday morning, we would meet and then I would start my clinical work at ten. And because it was first thing on a Monday, it worked. I think staff engagement is all about making time. Often you get the response, ‘Oh we’ve not got time to do it.’ But if you explain, hang on a minute, half an hour spent doing this could save you several hours during the week, it’s worth it. I think middle management in particular came to accept that, and their attendance at meetings was good. ‘We stopped cath lab activity. We had sessions in the coffee room. We ordered food, and we had all-day sessions on Fridays for two weeks. I went round the wards, I went over to West Suburbs and I badgered people asking them: what do you think, what’s wrong? The cath lab work was losing money, and if we carried on, we would end up in dire financial straits, and we might end up losing services and staff. So we asked, what are the issues? And we must have had two or three hundred post-its, we had emails – there was nobody backward about coming forward. And what they were saying was all true.

But when we did the process mapping, we could see that it wasn’t working. It took us six months to get that right. This indicates how staff had taken ownership of the process.’ (Cardiac nurse practitioner and project lead) And people who you had no idea had the skills came to the fore; care assistants, porters who, in their own way, were bright people with a lot to contribute. We had a guy who helped us with the collection and display of the data. He’s a booking clerk, but was interested in programming and data and displays. He was fantastic. He was a real enthusiast, and he came from nowhere. What part did organisation politics play? I’m usually good at sussing out where people are coming from and their personalities and agendas. From that point of view, I was suited to this process.
When I took on this role, we had colleagues who were less willing to change. If I challenged them, the rest of the group would come to their support. However, over time, as others became involved, they became more isolated. So I didn’t have to deal with them anymore because others would be doing it for me, which was gratifying. One colleague felt that I just had it all wrong. His view was that the new cardiac centre was a medical facility for the consultants. He said, ‘You can’t manage a high quality service by asking the cleaner what you should do.’ I said, ‘Well, I may not ask the cleaner for medical advice, but I might ask the cleaner for advice about what’s the best position to put this equipment.’ You have to be able to persuade colleagues to support your service. I saw colleagues trying to get funding by saying, ‘We’re the best service in the trust, so you have to invest in us, and we will be even better.’ And whenever they were asked for help, they would define themselves as a specialist group who needed to be treated differently.

But the group that they were applying to for resources was the general pool of other doctors. The emergency department had problems with waiting times. Patients come into ED, they are dealt with by ED, then dealt with by the general on-call doctors and then by specialists. Some specialists took the view that, ‘We’re specialists and this isn’t our problem.’ But for me, actually, we’re all part of this organisation, and if we as a specialist group show that we can engage with the front door, and support that part of the service, then my proposals are more likely to be supported because I’ve made friends in ED. And that’s what happened. I also had credibility because I was out and about in the hospital. On a Thursday I might be seeing patients as a cardiologist, and then on a Friday I’d be talking to them in a meeting about support for the development of the department. That wasn’t being underhand, to see patients and deal with them well because I wanted to get them to support the department the following day. But that helped.
Most doctors are competitive beasts. You turn it into a competition, and they’ll respond. They don’t want to be bottom of the class, not doing enough procedures or not turning up. Those who were underperforming would know, but it became a reality for them when it was there in colour, bar charts, documentation. So we then saw behavioural change in those individuals. Out of the twelve, I had two or three close allies who . . . whatever I asked, they would do. And then I had three or four who needed more convincing. Then I had the two or three who were much more resistant. I had the very senior guy who always had to say no first.

He would eventually agree, but never straight away. You always had to go through a bit of a charade. I knew that he’d say yes. But you felt like saying, ‘Look, I know in two months’ time you are going to say this is a great idea, so why don’t you just say it’s a great idea now?’ Why did you step down? It was a busy full-on management role. Not mental stress, but physical. Having done my stint, I was tired, and needed a break. The other reason for stepping down . . . appointed to a managerial post as a young consultant, you are still developing clinically. And in cardiology, the field changes quite quickly. I was appointing junior colleagues who could undertake procedures that I was missing out on in terms of my own development. Had I decided that I was going to be a full-time clinical manager that wouldn’t have been a problem, but I hadn’t made that decision, and I stepped down. I had one particularly difficult colleague. It was never meant to be personal, but he refused to engage, and took that out on me. Not a big deal, but I no longer had the energy to deal with him. I knew there was another wave of projects coming. And I knew that this guy would be difficult, and that this time around I wouldn’t have the energy to cope. Three years previously, I would.
Questions
1 What change leadership behaviours and attributes were important to this doctor in this change leadership role?
2 What political tactics did he use?
3 What are the challenges for change agents raised by this case?
4 What are the training and development, and other HR implications, raised by this case?