Rob Parsons of Health Partners International discusses how to manage, and gives introductions to two of HPI's products: The How To Manage series of guides for healthcare technology PLAMAHS – inventory and management software for medical equipment. The main focus of the presentation is on management.When we talk about healthcare technology management, we tend to talk a lot about healthcare and technology, but less about management. The purpose of this presentation is to introduce general management skills and show how they can be used in the jobs that you have, or will have in the future.
This is your speaker, Rob Parsons, doing what he does best.
HPI is a partnership of skilled and experienced professionals, providing high quality technical services for the health sector. We are specialists in health systems and management. Since 1995, we have initiated and supported lasting health initiatives in more than 30 countries across Africa, Asia, the Middle East, Latin America, the South Pacific and the Caribbean. We collaborate with local partners and stakeholders to find practical solutions to the challenges of health systems, often in difficult environments, to ensure sustainable health care is available for all, especially the poor.
PLAMAHS - Planning and Management of Assets in Health Services collates information on health sector physical assets to provide: - information on the status of the present asset base through inventory and maintenance information - reference to health and equipment policy in order to assess compliance with the policy - budgets in order to plan and allocate the available financial resources - procurement information, supporting the acquisition process of the appropriate equipment.
This Series of Guides aims to promote better management of healthcare technology and to provide practical advice on all aspects of its acquisition and utilization, as well as on the organization and financing of healthcare technical services that can deliver effective HTM. The Guides – individually and collectively – have been written in a way that makes them generally applicable, at all levels of health service delivery, for all types of healthcare provider organizations and encompassing the roles of health workers and all relevant support personnel.
Managers actually do all sorts of things, and they tend to do them very quickly. But the most important things they do can be encapsulated in the list on this slide. Each of these forms the framework for one session during this part of the workshop.
I know that many technicians and engineers prefer machinery to people. Machines don't answer back and don't have off days. But you can't be in a place where you have no contact with people like this igloo; you have to work on people, at people and with people if you are to do your job properly. Which is why my next slide says....
We tend to think of management as being done by people who have the word “manager” in their job title. In some sense those people do things the rest of us may not, as they usually have people reporting to them whose work they control. But the fact is that everybody, whatever their job title, and whatever their role and responsibility, uses management skills to get the job done. That will be clear if you think about the focus of management, as outlined on the next slide.
There are more definitions of “management” than you can shake a stick at. Here is a simple one which gets together the two key ideas. One is that management always has a purpose. The second is that it always involves getting people to do things. Everything else flows from this.
This slide gives you a bit more of an idea about how managers set about doing what they're doing. The key issue here is that management is active, always planning, checking progress, adjusting to take account of new circumstances, always looking for alternative solutions to problems. We get to Attila the Hun in slide 44.
Participants at the workshop got action cards at this point. Each card had five sections,one for each of the management activities listed in slide 6. At the end of each session the participants were invited to write one key point for later action from that session on their action card. These completed action cards formed the basis of the final activity for the presentation.
This is the beginning of the section on “managers know things”. My main point here was about knowing what we do, and I took Peter Drucker's habit as my starting point. He always began a consultancy with the senior management team, and he asked them one simple question, “What do you do?” He would not let them move on until they had all agreed to a simple definition of what the organisation did. Sometimes it took days, but until they had that basic agreement, there was no point in moving on. I invited participants to try telling others what they did in their jobs. Some found it easier than others. We had already noted that one of the big problems for clinical engineers was that other professionals did not know what CEs do. So CEs need to be able to tell them simply and convincingly. If you can't outline your job easily in one or at most two simple sentences, you need to work on it. Note: people often answer the question by saying what they “are”, not what they “do”. “I'm a clinical engineer”, isn't an answer to the question.
This is an illustration of the point. I was once in charge of a community centre called Brighthelm in Brighton, England. The purpose of Brighthelm was to get community work done in the surrounding area, but after my team and I had been running it for a few months we realised that it wasn't our job to do the community work. There were lots of locally based people who were better placed and better motivated than us to do that. Our job was to enable them to do their job by making the facilities of the centre as suitable as possible for their purposes. Our answer to the question “What do you do?” became, “We make space”. Very simple, clear to communicate, and very motivating.
A very good principle for managers to work with. Things can usually be a lot simpler than they are. People working in organisations tend to add bits and pieces to the policies and the rules with which they work. Always see if you can cut through through all the unnecessary rules to the ones that really matter. It's the Occam's Razor* principle of management. *Look it up.
We move on now to the second field – managers create information. I mention “knowledge management” at this stage as it is, deservedly, flavour of the month. Knowledge comes in two forms, what is on paper and what is in people's heads. The idea behind KM is to make the best use of all that information regardless of its source. KM is difficult to do on your own; your entire organisation's culture will determine how knowledge is managed. But you can do your bit in your own sphere, and one of the best things managers can do for those they work with is to make sure that they have the information they need to do their job. Sometimes the information is not there, sometimes it is there, but not in usable form, so it is your job as a manager of that field to get the information and to make it usable.
There is a great tendency to create information out of anything that can be measured. Measurable information has its place, but it is only part of the story. Organisations get too attached to numbers because they appear to be clear. You know what it means if you've achieved 50%, 70%, 100% or 120% of your target. But much of the information you need is unmeasurable – it's about people's reactions, about whether they use a new machine enthusiastically or with trepidation. It's often about whether they care. Never be frightened of information that doesn't come with a number attached.
The primary point here is that if you don't get the right information about the right things, you end up with confused staff and colleagues.
Curve A: Crisis Management: ◆ major periodic injections of new equipment ◆ poor preservation of existing stock Curve B: Stable Healthcare Technology Management: ◆ preservation (maintenance) of equipment ◆ regular planned replacement Curve C: Good Healthcare Technology Management: ◆ preservation of equipment ◆ regular planned replacement ◆ improved performance through internal learning processes Source: Remmelzwaal, B, 1994, ‘Foreign aid and indigenous learning’, Science Policy Research Unit, University of Sussex, UK This slide illustrates some of the effects of poor management and information. Line A show what happens if you don't make sure the team has timely information and good management. They go downhill till the manager makes an effort and pulls them up again, then they go downhill again....
This is the point at which we introduce the “How to Manage” guides for healthcare technology management. The idea behind the guides was to have a set of resources available which would enable any country or province to set up a healthcare technology management policy and system from scratch, if need be, and get everything in the right place. There are six guides altogether, all freely downloadable from the HPI website ( http://www.healthpartners-int.co.uk/our_expertise/how_to_manage_series.html ) and from other sites. There is also a course based on guide 2 housed at the Open University (UK): http://labspace.open.ac.uk/course/view.php?id=5842 The guides open with a statement of how healthcare technology fits into the entire healthcare system, as illustrated here.
This shows how the topics of each of the guides fit together. Organising and efficiency frame the activities of planning, procurement, maintenance and operation. The six guides are together about 1500 pages long and contain nearly half a million words. They go into everything in considerable detail. These slides do not cover the whole process, but rather give a flavour of the sort of thing you can expect to see if you use the guides. A selection of issues from the guides is dealt with in the next four slides.
This diagram illustrates all of the stages in the process of healthcare technology management. It shows how they all fit together, and how the whole process is cyclical.
This and the next slide are two different metaphors for the issue of lifecycle costs when considering how to budget and plan for healthcare technology. The cost of purchase is only one factor – spare parts, maintenance, consumables, repairs, training time, operating time, costs of decommissioning for some technology
The hippo illustrates the same issue as the iceberg – lifecycle costs. It does so in a more culturally appropriate way for Africans, and thereby illustrates another important theme of management. (This is not dealt with as such in the guides, but it's appropriate to raise it here.) With globalisation cultural awareness has become important everywhere nowadays. Many, many large companies operate across national and continental boundaries, so it is important to be aware that the people you are trying to deal with do things differently. It's more important in many African and Asian countries, though, where ethnic divisions are often contained within national boundaries. People in such places have probably grown up with a knowledge that people are different, but that knowledge needs to be revisited and honed for use in working together with colleagues, whatever their origins. There are a number of other issues that culture can throw up, and one of the most prevalent is that men have a variety of ways of not crediting women or listening to them. We are lucky to have numbers of women practising and training as clinical engineers, so this issue is going to be relevant in many workplaces. It is not something that should be accepted – all staff, male and female, in any workplace, must strive to ensure that everybody's voice is heard effectively.
This is another image familiar to anybody who has dealt with procurement and budget planning. The lifetime costs of a piece of equipment are bunched towards the beginning and the end of its life. The beginning includes commissioning and training costs, initial purchase of consumables and spares, and troubleshooting. Then we have a trouble free few years, and then costs begin to mount as the equipment gets older and requires more repair and maintenance. It may well be also that spares and consumables become harder to get and so more expensive. And that is the end of the series of snapshots from the How to Manage guides.
And we introduce PLAMAHS The trees represent: P-heavy – the full fledged Access based version P-lite – the soon to be ready free and open source version P-web – the MySQL based web version currently in production.
This diagram represents the possibilities that will be available when P-web is fully functional. Data can be entered remotely from a tablet computer, or if there is no connectivity data can be stored on the tablet and then merged into the main database later. It can also be collected on a sub-server via a local network and then again merged into the main database later.
PLAMAHS crunches data very quickly and in a very versatile fashion. But the key to its use is proper planning,entering and maintenance of the inventory, and proper policy making. HPI helps to train users to build the right policies and implement the right practices and decisions. The first part of inventory activity is crucial. Without accurate and complete entry of the equipment inventory, future decisions will always be based on inaccurate information. So the first entering of the inventory needs to be done exactly right,and to have time and people put aside to be dedicated to that task for as long as it takes. A key issue for management is that the data clerk who inputs the data is likely to be one of the lowest paid people in the team. You have a task to ensure that those people understand the importance of and are committed to accuracy in their work. We return to this in slides 40 and 41.
And it is not just about entering data on the system. Each item of equipment has to be identifiable later in its life, so the inventory taking process involves labelling all pieces of equipment with a unique number, and that number is noted and entered into PLAMAHS so that it can be clearly identified later on.
Teams of people drawn from different departments -finance,planning, medical, technical, facilities – will be involved in the planning. One of the key features of planning, which PLAMAHS is built to help with, is decisions about what to use as model lists for equipment for the various different facilities and needs. PLAMAHS has a number of widely used model lists built in to its database. Custom built model lists can be inserted if desired.
Budgeting is a key feature of any healthcare technology management system, and PLAMAHS is able to help with working out budgets for both procurement and maintenance.
This is the cast of Sex and the City, carrying out their habitual procurement activities. Procurement is a complex and often neglected part of healthcare technology management. PLAMAHS helps with model lists, drawing up specifications, predicting and planning for procurement.
One of the reasons why Heath Robinson was so brilliant is that his inventions always did the job they were intended to do, despite the technology looking decidedly ropey. For technicians doing their jobs, working with technical specifications, and maintenance guidance is crucial, and is facilitated by the data that PLAMAHS houses on each piece of equipment.
PLAMAHS can identify the precise geographical location of any piece of equipment, file photos of it at various stages of its life, store maintenance manuals and information, give a lifecycle position, and provide a detailed history. With the maintenance module (available in P-heavy) it can note both repair and preventive maintenance requirements, and produce and maintain job cards.
Model lists of equipment are provided. Custom lists can also be added. In the P-heavy version inventory can be compared with a model list to produce a gap analysis,and a list of equipment that will need to be procured, with indicative budgets. And that is the end of our introduction to PLAMAHS. Further details can be found at http://www.healthpartners-int.co.uk/our_expertise/plamahs.html For P-lite anyone can join the P-lite Google group at https://groups.google.com/forum/?hl=en#!forum/plamahs
We continue with management. One of the most important tasks for managing is shepherding. It is impossible to get people to do exactly what you want. They will always have different ideas, they will get enthusiastic about different things and in different ways to you. That does not matter as long as you keep people moving in roughly the right direction. Sometimes you can successfully instruct people to do something precisely, but it won't work all the time. In fact you don't want it to work all the time. The most valuable asset any colleague has nowadays is their initiative. If you give them precise instructions all the time, you will stifle that initiative. Tell them what you need to happen and give them the minimum help they need to work out how to do it. Their initiative will always find different ways of doing things, and that is absolutely fine. We will address this issue more when we get to Peters and Waterman (slides 50 and 51).
One of the most used modern ways of keeping people going in the right direction is Key Performance Indicators (usually shortened to KPIs). For KPIs you choose a number of things which you require people to report on at regular intervals. Four or five is common. Much more than that tends to dilute people's efforts. With KPIs it's very important to keep things simple (slide 14). There is a whole industry of KPI consultants, and bits of software, and theorising, and must haves that go on behind KPIs, but most of those serve only to confuse issues. Set on a few things that are clearly of major importance for your work and figure out how you can keep tabs on them. Notice that I carefully didn't say “measure”. KPIs are one of the worst areas for organisations measuring that which can be measured rather than that which is important. If customer satisfaction is important to you, for instance, you can't do it with numbers. Take surveys and collate the evidence; keep an eye on user forums on Google or Twitter or Facebook; keep a close eye on reviews in the papers and the specialist journals; talk to your customers (there's a revolutionary idea). Some indicators will be susceptible to measurement – that's fine.
This and the next slide refer back to one of the issues dealt with in slide 35. It derives from the saying, “Give a man a fish and he eats for a day. Teach him how to fish and he eats for life.”
But in this version he invents his own way of eating for life. It is a lesson in the fact that whatever you try to teach people they will learn what they choose to learn, and in their own way. It's important to let those exercises in creativity happen.
Portrait of John Kotter. He invented an eight step change process, outlined in the next slide. You can find more on this in lots of places on the net. Here is one: http://www.mindtools.com/pages/article/newPPM_82.htm
He said that in any change process you have to go through all the stages, and he also said that there were eight common errors, one at each stage, that prevented the process from working as well as it can. To my mind, they're all important, but if any are more important than the others, they are at the beginning and the end. At the beginning you need to know what you actually want to do – what your vision is. And,going right back to slide 12, you need to able to communicate that vision to your colleagues simply and clearly. And at the end,when the change has happened, it's very common to stop working and assume that things are going to stay the same. They won't if you take the pressure off straight away. They are likely to revert to the old state, or to somewhere halfway in between. You need to make sure the change is cemented.
This Caterpillar truck is one of Peters and Waterman's examples from their book “In Search Of Excellence”. It comes in here because it's a very good example of how to motivate people. A lot of what we've seen above, particularly in slides 27,36 and 40, is about motivating people. There is no one size fits all way to motivate people. You have to look at each person and each department. At Caterpillar they make these massive trucks. Testing the trucks is a really good job; you get to drive them over sand dunes in the desert all day long. But they also have people whose entire working lives consist of making nuts, or bolts, or washers in a factory. They answered the problem of keeping those people motivated to deliver good quality by taking them regularly to the testing grounds to watch the monsters at play. “ What do you do?” “ I make washers.” “ Well, there's three hundred of your washers in that wheel that's towering over you.” Always look for what works.
This slide and the next deal in more detail with the issue of culture. Geert Hofstede (this slide) came up with a way of describing different cultures according to five dimensions. These are: - power distance - individuality - masculinity - uncertainty avoidance - long term orientation. He suggested a three point scheme for dealing with cultural differences: - recognise: recognise the differences that exist - respect: respect those differences, don't just try to brush them aside - reconcile: then work to reconcile them so that people can work together. You can find out more from Hofstede's website: http://www.geert-hofstede.com/
Fons Trompenaars, with Charles Hampden-Turner, developed a seven dimensional model of culture. Five cover the ways people deal with each other.: 1. Universalism vs. particularism (What is more important, rules or relationships?) 2. Individualism vs. collectivism (communitarianism) (Do we function in a group or as individuals?) 3. Neutral vs. emotional (Do we display our emotions?) 4. Specific vs. diffuse (How separate we keep our private and working lives) 5. Achievement vs. ascription (Do we have to prove ourselves to receive status or is it given to us?) In addition there is a different way in which societies look at time. 6. Sequential vs. synchronic (Do we do things one at a time or several things at once?) The last important difference is the attitude of the culture to the environment. 7. Internal vs. external control (Do we control our environment or are we controlled by it?) This is from Wikipedia: http://en.wikipedia.org/wiki/Fons_Trompenaars Trompenaars also has his own Youtube channel, and is a very engaging speaker. Both of these schemes enable you to be aware of the cultural difference between people, and to make better decisions as to how to handle them. Neither is prescriptive: they don't tell you what to do, they give you the tools to work it out for yourself.
Every year brings a new set of management books and management nostrums. Some are snake oil, most are rehashes of good ideas that have always worked, but have been freshened up for the new year. One of my favourites, more than 20 years old, is Wess Roberts' “The Leadership Secrets of Attila the Hun”. It's short, very readable,and full of good ideas. Some people don't like it. That's one thing that is good about having so many books available – you can always find one that works for you.
This and the next slide are principles from Attila, and they are about being strategic. Sometimes you need to fight a battle to get what you want, but there's no point in fighting a battle you can't win. (Except in the very rare cases where you have to stand on principle.) So, think about what you're doing. If you cannot see clearly how you are going to win something, retreat and relax. If the battle is unwinnable,live with it. If the battle might be winnable, leave it for now, but prepare for it. Make allies. Even where you can't make allies as such, you can often soften people up over a period of time, by being reasonable and helpful to them, while keeping your idea on the boil. Strengthen your argument. Look for facts and figures that you can quote to help your cause. Don't give up on it, but choose your moment.
In the same vein, you need to keep an eye out for who are the powerful people around you. There are four kinds of power: - personal power: some people have just got it - position power: who's the boss - expert power: people who know things other people don't, or have skills other people don't - resource power: people who control access to things. The boss's secretary, and the keeper of the stores come to mind. People need to be respected for who they are as well as for what they can do. There is no point in needlessly annoying someone who is in a position to give you a lot of grief. So don't.
Now we move on to the next management skill. This is problem solving. Managers do it all the time. In fact everybody does it all the time. But some people do it better, and more systematically than others. The key lies in being systematic in your approach, and imposing yourself on the problem. The world doesn't come neatly packaged in discrete bits. Neither do problems. That is to say, only the easy ones do. If you've run out of paper, you order some more and make do till it arrives. But the kind of problem that takes the talents of a manager to solve is always a mess (rather like the mess on the front of this slide). A mess has no structure, no obvious point of application, no obvious route through to a solution. So the first thing you do is turn the mess into a problem. In other words, you impose some structure on it, and you use the structure to work your way towards a solution. As you gain experience in problem solving, you learn to understand where structures may emerge from messes. A common issue for instance with anything concerning money is about controlling the cash. If you stop anybody spending anything with your authority, for instance, it becomes easy to see where the pressures are (and to conserve your bank balance as well). With work scheduling, if there are competing methods of authorising work getting in the way of each other, then insist on only one, a new one if necessary, and see how the flow is going.
In problem solving, leadership is important. Leadership is like management – everybody does it, even if they don't have leadership positions as such. If you want something done, the odds are that you will have to lead it. So don't be afraid to put yourself forward when it's relevant. Other people will thank you for it in the long run.
Whether or not you're leading or managing at any particular time, do make sure to get on top of things. Take what is called a helicopter view. Don't look just at your own job or your own department, take a look at what is happening in the whole organisation. It's an important part of both management and leadership. (People often use the two words pretty much interchangeably by the way. To my mind leadership leans slightly towards the more social issues around influencing people to get them to do what you think they need to do.) You need to do it regularly so that when a problem occurs that needs your attention, you know what the ground outside is looking like before you start.
These two are more of my favourite authors. Although they worked together for a long time, I couldn't find a photo of the two of them together. I've no idea whether that means something or not. Their first big book “In Search of Excellence” examined a number of companies and came up with eight characteristics of excellence: - A bias for action, active decision making - 'getting on with it'. Facilitate quick decision making & problem solving tends to avoid bureaucratic control - Close to the customer - learning from the people served by the business. - Autonomy and entrepreneurship - fostering innovation and nurturing 'champions'. - Productivity through people- treating rank and file employees as a source of quality. - Hands-on, value-driven - management philosophy that guides everyday practice - management showing its commitment. - Stick to the knitting - stay with the business that you know. - Simple form, lean staff - some of the best companies have minimal HQ staff. Simultaneous loose-tight properties - autonomy in shop-floor activities plus centralized values. Their work has been criticised by many, and it is noticeable that many of the companies they portrayed in their book as excellent went on to less than stellar performances in later years. But the principles still hold good. You can have these characteristics and not be excellent. But if you want to be excellent, chances are you'll need to have them.
To my mind, one of the key properties of excellent organisation is their final characteristic; simultaneous loose tight properties. This goes back to a lot of what we have already talked about – in slides 12, 35, 36, 38 and 40, for example. Peters and Waterman talk about values rather than goals, but it comes to the same result. The tight bit is being clear about what the organisation's values are. The loose bit is in giving employees a considerable amount of autonomy in how they set about actualising those values. That can be a hard thing to do, because as we discussed in slide 38, people have their own way of doing things and it may not be to your taste. It involves giving up power. It needs to be done.
This final slide is about planning. This has partly been dealt with in the work on Kotter, slide 40, where he talks about creating small wins. When you're planning to do things, plan manageable stages. Give yourself and other people milestones that they can understand and by which they can measure their progress. (You see, I'm not against measurement in the right places.) And plan in celebrations when you make those milestones. A celebration can just be a handshake or a cup of tea, but it's important to make sure that you get them in. that's part of recognition, and when you recognise the achievements of your subordinates or your colleagues, you put a smile on their face. That is the end of my presentation for the ICEW workshop, so there only remains one thing for me to say.....
Icew workshop hpi_sv
International Clinical Engineering Workshop, Pune, 2011 PLAMAHS and the art of management How to get the best out of both people and healthcare technology Rob Parsons [email_address]
Each slide has notes attached, going into detail about the topic of the slide .
Health Partners International Partnershi p Health systems and management Practical
Give a man a fish and he eats for a day. Teach him how to fish...
… and he sits in a boat drinking beer all day long
Establish a sense of urgency Form a powerful coalition Create a vision Communicate the vision Empower others to act on the vision Plan for and create short-term wins Consolidate improvements and producing still more change Institutionalise new approaches