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The London Pathfinder Toolkit Booklet Three: Tools and Interventions

Contents

Page

About this document 1

Introduction 2

Diagnostic tools – introduction 3

Diagnostic tool 1 – 360° leadership assessment 4

Diagnostic tool 2 – team assessment 6

Diagnostic tool 3 – organisational assessment (Pathfinder Roadmap) 10

Development plans 12

Development interventions 15

Case studies and Resources 22

Appendices 27

Appendix 1 – example LPI 28

Appendix 2 – development plan templates 29

This document is the third in a series of four booklets which make up the London Pathfinder Toolkit. The Toolkit comprises these booklets, supported by a set of additional resources, which will are available on London’s Online Pathfinder Network. The Toolkit provides the core of a development support programme for London’s pathfinders and has been designed to be implemented by one of the providers on NHS London’s Leadership and Organisational Development framework. It is intended to be an interactive and developmental Toolkit and not a written exercise.

The Toolkit is transitional and incorporates the best current understanding of a range of stakeholders (including clinical, pathfinders, national authorities and experienced commissioners). As more information becomes available from the Department of Health, this Toolkit will adapt to incorporate the changes.

The pyramid on the right illustrates the booklets that make up the Toolkit.

The aim of this booklet is to introduce the diagnostic tools and development interventions which have been used with pathfinders in the first period of support, the outputs from those tools, and the lessons learnt.

NHS London commissioned the KPMG Partnership for Commissioning to work with eight of London’s first pathfinders to develop and test the Toolkit. The Toolkit has also been tested with other pathfinders and stakeholders, including representatives from primary care organisations.

It is intended to support development of local options for pathfinders and not dictate solutions.

About this document

A glossary can be found in Booklet 1 of this series, with a more detailed version available in the Health White Paper “Equity and Excellence: Liberating the NHS” (page 54 onwards).

A comprehensive list of acronyms can be found on the NHS Connecting for Health website at http://www.connectingforhealth.nhs.uk/about/acronyms

Booklet 1 Context: an overview of the Toolkit and why it has been developed

Booklet 2 Roadmap: the London Pathfinder Roadmap, which will enable a pathfinder to map out its own development plan

Booklet 3 Tools and Interventions: the diagnostic tools and interventions that support the implementation of the toolkit

Booklet 4 Theory and Practice: the theory and practice underpinning the toolkit

1 | Booklet 3: The London Pathfinder Toolkit

Introduction

Pathfinders are, in most cases, new teams facing complex decisions and often requiring new or enhanced skills.

To be successful commissioners of care, the pathfinder leadership team may benefit from specific resources to help develop the skills required.

This booklet introduces the diagnostic tools available to assess individuals, teams and pathfinder organisations. It describes how to translate the findings into comprehensive development plans to generate momentum and achieve results and summarises relevant interventions that are important to deliver these results. Specific case studies and references are then included.

1. Diagnostic tools

Leadership assessment – Individual leadership skills equip pathfinder leadership team members to create and share their visions, make decisions, and lead teams to deliver results. The Kouzes & Posner Leadership Practices Inventory is a 360° assessment tool which provides feedback on opportunities to enhance individual leadership skills.

Team assessment – Team skills help the leadership team and other leaders work together to develop shared objectives, agree clinical decisions and motivate the wider clinical community (including GPs, the acute sector and community care). Team skills are important when learning to collaborate to design care pathways and protocols that create value for the population. The Aston Team Performance Inventory is a team assessment tool that provides insight into how current team dynamics can be enhanced.

Organisational assessment – Pathfinder or organisational skills represent the broad operational capability required to achieve full accountability and responsibility for commissioning care. The Pathfinder Roadmap is both a development and assessment tool to help pathfinders identify how far they have progressed towards being ready to meet the challenges of full authorisation. The Pathfinder Roadmap also provides guidance as to potential gaps and next steps that can help pathfinders assemble a comprehensive development plan.

2. Development plans

Using the assessment tools, pathfinders will identify their current position in relation to organisation goals, compare to where they want to be, and create comprehensive development plans that define goals, interventions, decisions; and milestones at the individual, team and organisational level. These plans will have goals that are specific, measurable and attainable, and have associated timeframes. Pathfinders will be able to select from development interventions to help them complete their plans.

3. Interventions

Interventions are practical ways of deriving value from the assessment tools and development plans. The list given in this booklet is representative, not exhaustive, and includes common facilitation techniques to assist at the individual, team and pathfinder organisation level. These activities are important to delivering the results of the development plans.

4. Case studies

Case studies are representative stories of how some of the first pathfinders have put the tools, development plans and interventions into practice, in order to deliver outcomes which are meaningful. They present the problem, the solution and the outcome, to provide a realistic example of how theory has been put into practice.


Successful teams understand their individual strengths and weaknesses, and pathfinders will be no different. Gaining a picture of the strengths of the pathfinder leadership team will be important if their effectiveness is to be maximised.

One of the diagnostic tools which has been used with pathfinder leaders is a 360° feedback assessment of their leadership skills. This type of approach was explored in a BMJ article in September 2010 (see Resources section) which concluded that multi-source (or 360°) feedback could have a significant impact on clinician behaviour if the source of feedback is seen as credible. 360° feedback has been used for many years with clinical and non-clinical leaders in the NHS. It is a powerful tool for leaders to understand the impact they have on others.

This booklet outlines the three main diagnostic tools that have been used with the early pathfinders. The booklet describes what the tools are, how they are used and the experience gained from using them. The tools have been chosen as complementary with a focus on the development needs of the individual, the leadership team, and the pathfinder organisation as a whole.

Diagnostic tools – introduction

The tools are:

Kouzes & Posner – a 360° leadership approach that is focused on the individual and their development needs. It is based on the five practices exhibited by outstanding leaders.

Aston Team Performance Inventory – this examines the working of the leadership team and identifies areas for team development. This tool includes analysis of leadership and team processes to help the pathfinder maximise their effectiveness as a senior leadership team.

The ‘Pathfinder Roadmap’ can also be used as a diagnostic tool for the organisation. This booklet has a short section on the Roadmap but a more comprehensive explanation is given in Booklet Two.

The range of tools available to pathfinders

Individual leadership development

360° Survey

Coaching

Team leadership development and dynamics

Self-Assesment

Observation

Feedback

Organisational development and effectiveness

Pathfinder Roadmap

Expert Workshops

Engagement Sessions

Challenge Sessions

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What is it?

The Leadership Practices Inventory (“LPI”), is a 360° assessment tool which helps leaders assess the extent to which they lead others according to the Five Practices of Exemplary Leadership® model, developed by Jim Kouzes and Barry Posner.

The five practices are:

– Model the way – Inspire a shared vision – Challenge the process – Enable others to act – Encourage the next

Independent studies consistently confirm that the LPI has very strong reliability and validity. Today, it is one of the most widely used 360° leadership assessment instruments available. More than 250,000 leaders and nearly one million observers have completed it.

The individual report provides benchmarking information using their vast database.

A facilitated team discussion is recommended to build a picture of the whole team’s strengths and gaps.

How to make it happen?

The LPI 360° is a questionnaire with thirty behavioural statements, six for each of The Five Practices®. It takes 15 to 20 minutes to complete online.

Leaders complete the LPI–Self, rating themselves on a ten–point scale indicating the frequency with which they think they engage in each of the thirty behaviours.

Five to ten other people (usually eight) invited by the leaders, complete the LPI–Observer questionnaire, rating the leaders on the frequency with which they think they engage in each behaviour.

Respondents indicate their relationship to the leader – manager, co–worker or peer, direct report or other observer. With the exception of the leader’s manager, all the observers’ feedback is anonymous.

What are the outputs?

A 16–page individual report is produced which highlights the frequency of the leader’s behaviours compared to the ratings of the observers.

An example report can be seen in Appendix 1 of this booklet.

Results are presented at three levels:

– Comparison of the leader’s scores compared to those of the observers in each of the Five Practices®

– Comparison of the leader’s scores compared to those of the observers in each of the six behaviours within each of the Five Practices®

– A ranking of all thirty behaviour statements from those observers reportedly seen most frequently down to those they observe least

All results are presented in table and bar chart formats.

How do you use it?

The primary goals of 360° feedback on leadership behaviours are to:

– Pinpoint development needs – Provide opportunities to change

behaviour – Improve leadership performance

The report generated together should then create the content for the personal development plan (“PDP”). This will set out the agreed actions to be taken to improve the leader’s performance.

An example PDP is shown in the next section and a template for completion will be available to download from London’s Online Pathfinder Network. This is referenced in Appendix 2 of this booklet.

Leaders who consistently demonstrate the Five Practices have been shown to:

•Bemoreeffectiveinmeeting job demands

•Bemoresuccessfulinrepresentation to senior management

•Createhighperformingteams •Fosterloyaltyandcommitment •Increasemotivationallevels •Reduceabsenteeismand

turnover

Diagnostic tool 1 – 360° leadership assessment


The following is a summary of potential questions to help the individual leader think through the results of the LPI 360°. They are not exhaustive and are illustrative.

Summary page

•Lookingalongeachrowatthedifferent scores – what concerns you?

•Whatpleasesyou?

•Lookingdowneachcolumn–whatdoes that tell you about any areas for development?

•Whatdoyouseeasyourkeystrengths – is that view shared by others – what does that tell you?

Raw score page

•Arethereanypatternswhichyousee looking along the rows and down the columns?

•Whatconclusionscanyoudrawfrom this?

•Wouldyousaythisareaisastrongone for you?

•Whatwillyoubelookingtodevelopas we go through the programme?

Rankings page

•Doyouseeanysignificantpatternsat the top and bottom of the rankings?

•Doesthisconfirmorconflictwithanything we have discussed already?

•Whichareasorstatementswouldyou like to consider specifically?

•Whatconclusionsareyoubeginning to reach about your strengths as a leader?

•Whatwouldyouregardasapriorityat this stage?

•Howdoyouintendtosharethisfeedback with your “observers”?

LPI 360° – coaching questions


Diagnostic tool 2 – team assessment

The Aston Team Performance Inventory (“ATPI”) is one of the most comprehensive tools available to benchmark current and predict future team performance in organisations.

Developed from over 20 years of research evidence from Aston Business School, ATPI identifies and measures the key elements of effective team working at both team and organisational levels.

Itexaminesthefactorsinfluencingteam effectiveness in three distinct areas by:

– Assessing the main inputs or contextualfactorsthatinfluenceateam’s performance

– Assessing team and leadership processes

– Evaluating the team’s outputs and performance

How to make it happen:

The ATPI is an easy–to–administer questionnaire which takes approximately 15–20 minutes to complete.

First, all the names and email addresses of the leader and team members are collated.

Each team member then receives an on-line invitation to complete their ATPI questionnaire from Aston Organisational Development Ltd.

All answers are confidential.

A deadline of normally a week is set for completion.

What are the outputs?

Results are presented in a comprehensive 14–page report, giving feedback about how the team is performing in relation to teams in a relevant comparison group. The report covers the following areas:

– Team Inputs

– Team Processes and Leadership

– Team Outputs

The report also highlights levels of agreement between team members about the way in which the team is performing.

How do you use it?

The feedback report allows the team to identify areas of strength and weakness.

The process of reviewing the ATPI feedback report provides a sound foundation for improving performance.

Team development initiatives can then be more accurately tailored.


The following pages give an example of how the ATPI self assessment was used by one pathfinder. They include two key aspects which are:

Team member perception

•Averagerating

•Ratingscale1–5

Level of agreement

•Betweenteammembersaboutaverage rating

The in-depth report provides a summary of the team against a comparison group and forms the basis of a two–hour review and planning session with the team.

Team Overview

Aston Team Performance Inventory

Team

Pro

cess

5 Objectives Moderate

6 Reflexivity Moderate

7 Participation Moderate

8 Task Focus High

9 Team Conflict Moderate

10 Creativity and Innovation Moderate

Lead

ersh

ip

Proc

ess

11 Leading High

12 Managing Moderate

13 Coaching Moderate

Team

inpu

ts

Dimension 1 2 3 4 5 Agreement

1 Task design High

2 Team Effort and Skills High

3 Organisational Support Moderate

4 Resources Moderate

Team

Pro

cess

14 Team Member Satisfaction Moderate

15 Attachment Moderate

16 Team Effectiveness Moderate

17 Inter–team Relationships Moderate

18 Team innovation Moderate

Your Team

Comparison Team

Range of responses


The ‘team inputs’ element of the ATPI explores the way in which the team has been set up to be effective. For example, is there a clear, shared and defined task for the group that creates a team in the first place? The diagnostic assesses whether the team has the correct skill mix and the capacity to deliver the task in

hand. The diagnostic will also help assess whether the organisation as a whole provided effective resources and other support to deliver the task. This will be an important consideration for pathfinders as they develop and implement their commissioning strategy.

Response Scale 1 2 3 4 5 Mean

Your Team 3.15

Comparison Group 3.69

Team InputsOverall, your team has scores that are in the well below average range on dimensions that measure Team Inputs.


Your Team 3.64


1. Task DesignOverall dimension score: well below average (WBA)Level of agreement: high


Your Team 3.06


2. Team Effort and SkillsOverall dimension score: well below averageLevel of agreement: high

Team member motivation

Appropriateness of skills

Team Potency

WBA BA A AA WAA

The components that make up the Task Effort and Skills dimension are:

The team does not appear to have the right mix of skills to achieve the team task although team members are moderately confident that the team will be successful. Individual team members report very low levels of motivation.

Example ATPI self assessment

Independence

Feedback

Task relevance

Autonomy

Complete Task

WBA BA A AA WAA

The components that make up the Task Design dimension are:

In this example team members report that the team has a challenging task to perform which is seen to be very relevant to the overall aims of the organisation. Team members generally need to work independently however, the team does not appear to have much autonomy to decide how its work is carried out. Team members receive little feedback about team performance.

Key:WBA Well below averageBA Below averageA Average

AA Above AverageWAA Well Above Average


ATPI report

The ATPI report generates a series of ratings which show how members view the overall team’s performance.

The areas covered include:

• Teameffortandskills• Objectives• Teamconflict• Creativityandinnovation• Leadershipprocess• Inter-teamrelationships

The ratings then show how the team rates itself and whether there is a significant discrepancy of scores within the team.

The team should then have a facilitated discussion to consider areas where the score is low and to identify corrective actions. Where scores are mixed the discussion should focus on why this is so and actions to improve. Where the team scores highly discussion should focus on how they can be maximised and principles that could be successfully applied in other areas.

Team development plan

The report generated together with the subsequent facilitated discussion should then create the content for the team development plan (“TDP”). This will set out the agreed actions to be taken to improve the overall performance of the team.

The TDP will focus on reducing the perceived areas of weakness and build on the areas of strength. The plan should also ensure that any capability gaps are addressed through either individual development or collectively as a team. This might mean a focus on some specific skills such as improved working with partners or the whole team agreeing how they will divide responsibilities for managing contracts with local hospitals.

An example TDP is shown in the next section and a template for completion will be available to download from London’s Online Pathfinder Network. This is referenced in Appendix 2 of this booklet.

ATPI – team report and team development plan


Working with pathfinders in a complex environment is an exploratory exercise. To complement the assessment tools, providers undertook a series of other interventions to challenge current thinking, explore issues and identify development needs. Some of these interventions are outlined on the following pages along with the Pathfinder Roadmap.

All of the interventions enable pathfinders to complete responses to the Pathfinder Roadmap – a model designed to help consortia understand current capabilities and capacity and prioritise gaps in those capabilities. This leads to the design of an organisational development plan, an example of which can be seen in Booklet Two. A template for completion will be available to download from London’s Online Pathfinder Network. This is referenced in Appendix 2 of this booklet.

The pathfinders will require support to develop the Roadmap and to ensure that there is a strong link to the individual leadership and team development plans. The detailed development level three questions should be viewed as relevant to the team and in many cases the individual. For example, where tasks within the leadership team have been allocated to specific individuals, it is sensible that this individual leads on answering pertinent level three questions. In instances where the whole leadership takes responsibility – governance for example – then the team should work through the relevant level three questions and agree actions.

By combining the individual and team development actions, with the pathfinders roadmap actions, the organisation will have a good opportunity to ensure it is focussed on effective interventions to improve population health.

Diagnostic tool 3 – organisational assessment (Pathfinder Roadmap)


Working through the Roadmap

A detailed explanation of the Pathfinder Roadmap is provided in Booklet Two. This page highlights some of the lessons from the initial development phase of the

Roadmap and how pathfinders have used it to accelerate development. More details of work with one pathfinder is given later in the booklet.

DomainsA number of the first pathfinders worked through elements of the Roadmap questions to begin to identify development needs. Vision and Strategy was used by a number to clarify their overall purpose and strategic goals. Some pathfinders found it helpful to work through Vision and Strategy as a leadership team before then opening up the discussion to the practices across the pathfinder. Level three questions were valued.

EMPOWERING PATIENTS AND THE PUBLIC

PEOPLE (Skills and Capacity)

PROCESS

INFORMATION AND TECHNOLOGY

VISION AND STRATEGY

FINANCE

LEADERSHIP

CLINICAL GOVERNANCE CORPORATE

PLANNING

MONITORING

AGREEING

Transforming health outcomes

Improving value for money

Transforming health outcomes and value for moneyAt the heart of the model is the dual objective of improving both clinical outcomes for patients and population and doing so with a significant improvement in value for money. The actions that the pathfinder take to implement the commissioning strategy will be vital to delivering the twin objectives of improving population health and delivering value for money.

EnablersWorking through the Roadmap starts to shape the thinking around support for commissioning. Using the Roadmap level two and three questions the pathfinder will be in a better position to identify the services and skills that are best provided in-house and those which might more appropriately be procured from an external support organisation.

The ‘expert sessions’ that were run also helped shape the thinking of many as the skills and knowledge required to successfully implement the commissioning strategy became apparent.

Level 3: Supporting questionsPathfinders used this detailed level of questions (see Booklet Two Appendices) to probe and challenge their progress so far identify their development needs.

Pathfinder experience of using the Roadmap

Level 2: Development questionsPathfinders found these questions particularly helpful to ensure that they drilled down into the key areas. Planning was a domain that was used for this purpose. One pathfinder, for example, used the Roadmap level 2 questions to consider how to commission a more effective planned care service.

PLANNINGWhat specific steps are needed to implement the plan?

Level 1: DomainsThe Vision and Strategy domain was widely used by pathfinders. The overall ‘framing’ question was considered helpful in focusing on the broad purpose of the organisation.

How pathfinders will transform health outcomes and improve value for money.

VISION AND STRATEGY


Development plans

Using the diagnostic tools, pathfinders will identify where they currently are, compare to where they want to be and create comprehensive development plans that define goals, interventions, decisions and milestones at the individual, team and organisational level.

These plans will have goals that are specific, measurable and attainable and have associated time frames. Pathfinders will be able to select from activities and interventions to help them complete their plans.

The following pages include examples of personal and team development plans. Organisational development plans are covered in Booklet Two of the series.

Templates for all three plans are referenced in Appendix 2 of this booklet. These templates can be downloaded for completion from London’s Online Pathfinder Network.

An example personal development plan

A personal development plan (“PDP”) is an important tool for individuals in effective teams. The PDP will show future objectives and a record of achievement.

The PDP should be developed following individual feedback from the 360° diagnostic and the team diagnostic (such as ATPI). The aim of the PDP is to set out development objectives with stretching, but achievable, timescales for achievement.

The PDP is a key element of the ongoing learning log which can be found on London’s Online Pathfinder Network.

Development need (as identified through 360° and coaching)

Action & Timescale Resource Requirement Success Measure

Knowledge • Understandingcorporategovernance processes to develop workable pathfinder processes – 3 months

• Understandingofstrategicfinancial risk and mitigating actions – 6 months

• Governanceworkshop–input from legal advisors

• Financeworkshop–plusongoing coaching from financial advisors

• Demonstratepersonalroleplayedineffectivedecision making

• Demonstratepersonalcontributiontodelivery of QIPP plan

Skills • ‘Chairingskills’formoreformalmeetings to support good governance and enable better decision making – 1 month to set immediate ‘tone’

• Pathwayredesignskills

• Coachingresourceandfeedback from colleagues

• Facilitatedactionlearningset

• Levelofconfidenceimprovesandpositivefeedback from colleagues

• Pathwaychangedandmoreeffective(lessstepsfor patient, more effective)

Behaviours • Develop high–level influencing skills particularly with stakeholders in the local authority and at cluster level – 6 months

• Coachingresource • Levelofconfidenceimprovesandpositivefeedback from colleagues – could include effective relationships at local authority and cluster level


An example team development plan

The team development plan (“TDP”) is best designed as a group at the end of the facilitated discussion about the results of the team feedback. This ensures it is immediate, relevant and shared across the whole team.

The content of the plan should focus on the whole team actions as opposed to individual action (which should be picked up in the PDP). The plan can include issues of building capacity, capabilities and relationships as demonstrated in the example opposite; this example will also link directly to the organisational development plan (see Booklet Two).

Development need (as defined by ATPI report)


Inputs • Agreewithclusterthecapabilities and capacity required to deliver delegated responsibilities

• OutputsofPathfinderRoadmap self assessment

• Timewithclusterlead• Financialresourcesandexpertiseto

widen capabilities

• Resourceagreed by April 2011

• Fullsupportteam in place May 2011

Team Processes • Specifiedtime-outasateam to understand each other’s capabilities and define portfolios

• Identifiedtime • Agreedportfolios

Leadership • Clarity of leadership on roles and supporting roles of executive team

• Roledescriptions in place

Delivery of outputs

• Delivery plan agreed for the delegated responsibilities

• Identifiedtimetoagreeplanplusclearsupport resources from cluster

• Deliveryplanagreed


Development interventions

The following pages provide practical advice on how interventions can be used to support and develop individuals, leadership teams and pathfinder organisations.

The framework provider selected by the pathfinder will work with the leadership team to assist them with these activities. This will inform the creation of personal, team and organisational development plans.

A number of examples of the interventions that pathfinders have undertaken are provided. They are intended to give a picture of the range of options available to pathfinders as they start to move towards authorisation as a statutory body. These activities all form part of the ‘Roadmap’ of support for pathfinders and the examples givenreflectthedifferentstartingpositions of each pathfinder.

The examples are followed by some guidance on how to choose the right intervention and evaluate the outcomes.

Example 1 – Challenge session with a pathfinders

How:

These sessions have been short, informal, round table discussions with small groups. They have been lunchtime or evening sessions.

Expected outcomes:

•Reviewedpathfinderplans•Greaterknowledgeofkeyareas

such as governance or finance, applied to the local challenge

What we did:

Experts in different fields (governance, finance and commissioning capabilities) met with a pathfinder in an informal workshop setting to challenge current thinking on the mission and vision.

The pathfinder presented their current strategy and through a process of challenge and dialogue, began to explore the edges of the issues and refine their approach.

Outputs:

This was a new style of unstructured learning for the pathfinder whose initial reaction was to ask for a presentation and expect to be ‘told’ the answer. However, once the complexity of the issues started to emerge through debate, the pathfinder appreciated the opportunity to explore the “unknown unknowns”.

As a result the pathfinder was able to update their strategy and felt confident to take this stage two strategy to the wider primary care community.

The ‘experts’ may need the support of a facilitator who is able to work in an unstructured way and still get to a productive output.

VISION AND STRATEGY


How:

This session was an afternoon session with lunch from 1.00pm to 3.30pm. Attendance included 34 primary care practitioners including the pathfinder leadership team, GPs, practice managers and community nurses.

Expected outcomes:

•Sharedunderstandingof pathfinder aims

•Developedmodelsforclusteringarrangements across the patch to deliver the pathfinder aims

•Understandingofresourcerequirements to deliver clustering

What we did:

Following a brief presentation by the chairs on current context and aims of the pathfinder, the group discussed opportunities and challenges presented by pathfinder status. This became an extended discussion as it became clear that this was the first time they had the opportunity to discuss key issues such as values, style and benefits.

Two GPs then presented different views of how the pathfinder could set up cluster arrangements in primary care to support delivery of the pathfinder aims.

The wider group then had the opportunity to discuss the following questions:

– What is the definition of a successful cluster?

– What should primary care clusters do?

– What shouldn’t primary care clusters do?

– What is within their scope?

– What resources are needed for clusters to operate effectively?

– What are the pros/cons of each suggested model of clustering?

– Are there alternative models?

Outputs:

As an output of the day, the group produced a summary report. This summary was circulated for a brief period to enable further comment and then enable a decision on clustering to be made at the pathfinder leadership team meeting. It was made clear that all practices were expected to conform to that decision.

Example 2 – GP engagement session with a pathfinder

CORPORATE GOVERNANCE


How:

The session was planned to bring together key leaders from a pathfinder and the local authority in a short two hour afternoon session.

Local authority officers including the Director of Adult Services were in the room with GP leads from two pathfinders and their management leads. This group will be supporting the shadow Health and Wellbeing Board (“HWB”).

Expected outcomes:

•Sharedunderstandingofthecommissioning landscape

•Longlistofprioritiestorecommendto shadow HWB by the end of March, and a process for prioritising

•Agreeoperatingmodelfor the HWB

The Agenda:

•The current commissioning landscape

Brief presentations from key partners:

– Public Health – the health and wellbeing needs of the population

– Pathfinders – where we are now and our current priorities

– PCT/local borough council – QIPP plans and savings plans

•Table discussion – What are the key challenges and

key priorities?

– Where should the shadow HWB be focusing?

– What criteria should we use to shortlist our priorities?

•Our operating model – What are the opportunities for

this group to work differently? What is our vision for this group?

– Working behaviours – what should we start doing, stop doing and continue doing?

•Next steps

Outputs:

•An agreed list of priorities

•Asharedmissionstatement

•Aworkprogrammeforthefollowing 12 months

How:

A usual meeting of the pathfinder leadership team was dedicated to a review of the Pathfinder Roadmap. GPs and their management support team met for 11/2 hours over lunch.

What we did:

The key elements of the Pathfinder Roadmap were printed onto posters and the pathfinder worked in small groups with a facilitator to complete a self assessment of current capacity and capability.

The groups moved around the posters to build the view of current capabilities and identify actions for development. This event was planned 8 weeks after the start of the programme, enabling the GPs to have a deeper understanding following development sessions.

The pathfinder had an initial tendency to self assess to a high level. Challenge from the facilitator based on knowledge of the pathfinder would help.

The pathfinder leaders had differing views of current strengths and a negotiated agreement on the final ‘score’ was required. It seemed that the wider leadership team were less confident about capabilities which possiblyreflectedthelevelofdiscussion they had been involved in previously.

Outputs:

As a result of the self assessment, the group produced the first iteration of an organisational development plan.

Example 3 – Pathfinder/local authority session Example 4 – Pathfinder Roadmap session

LEADERSHIPEMPOWERING PATIENTS AND

THE PUBLIC

VISION AND STRATEGY FINANCE LEADERSHIP

CLINICAL GOVERNANCE CORPORATE

PLANNING MONITORINGAGREEINGEMPOWERING PATIENTS AND

THE PUBLIC


The range of interventions

Working with pathfinders requires a degreeofflexibilityandadaptationofdevelopmental techniques to ensure they are effective. There are a range of potential development interventions that will support pathfinder as they progress towards authorisation.

These can include:

Strategic decision making and leadership behaviours

•Seniorteam‘lock–in’

•Simulationworkshops

•Scenarioplanningand modelling sessions

•Challengesessions

•Engagementsessions

•Coaching

•Actionlearning

Skills and knowledge

•ExpertsessionsandCommissioning guides (as outlined in Booklet One)

•Workshops

•“OrganisationalRaids”to learn from others quickly and efficiently

•Onlinelearning(tobefacilitated by London’s Online Pathfinder Network)

Development interventions – choosing the right intervention

Choosing the right intervention

When designing the right development intervention to suit need, the following criteria should be considered:

– What is the development need? If the need is about behavioural change then a reflectiveand/orimmersionintervention such as coaching; or a simulation is most appropriate. If the need is more about developing skills or knowledge then an interactive workshop, use of case studies or organisational raid would be better. In order to develop a new strategy or gain alignment, then a time–out with the right group, such as a ‘lock–in’, would be right.

– What is the learning style of the individual/group? Are they activists,reflectors,theoristsetc?What style of learning will suit them best?

– What time is available? This is a particular criteria to consider for GPs who will have limited availability. Consider short sessions, evening sessions and on–line learning as appropriate delivery options.

– Is there a cost limitation? Be clear about the return on investment needed and ensure that costs of programmes will stand up to external scrutiny – i.e. is this the best use of taxpayers money?

– Are pathfinders requiring generic learning materials? Or is a more tailored development intervention appropriate, perhaps to solve a specific problem?


This list of interventions is not exhaustive but provides some ideas of options available to pathfinders that have proven successful to date.

Short workshops

• Lunchtimeoreveningtwo-hourworkshops that explore specific issues such as implementation of the local QIPP plans applied to a local context

• Explorationofdifferentissueshelps to frame the question properly and potentially move to a solution or key actions

Group coaching

• Shorttwo-hoursessionstofeedback results of team assessments, look at patterns of individual strengths and to feed back observations

• Thesessionsshouldresultinanewor updated team development plan

Challenge sessions

• Shortandinformal,thesesessionsbring together pathfinder leaders and experts from appropriate fields such as governance or finance, to ‘test’ an issue or plan

• Thesessionresultsinarenewedpathfinder plan of action

One-to-one coaching

• Individualsessions–face-to-face or by phone – will provide specific and focussed support based on individual development needs. A session may include feedback from a 360° diagnostic tool

• Asaresult,theindividualmayupdate their learning log and can further develop their own PDP

Scenario planning

• Oneormorepathfindersuseahalf-day session to explore a specific issue together (such as the local provider landscape), and consider the consequences of different scenarios

• Asaresult,thepathfindershaveagreater depth of understanding of the issue and potentially have an agreed way forward

Expert session

• Short,two-hourworkshopsconsisting of expert input – such as using data or governance – facilitated by an active question and answer session applying the expertise to local issues

• Asaresult,pathfindermemberswill have a greater knowledge of one area where they will apply their decision making

Engagement session

• Alargeandinteractivegroupsession with other members of the pathfinder, the aim being to share and build key ideas

• Asaresult,pathfinderscanensurethe support of their wider constituency

‘Lock-in’

• Thisisatermusedforprotectedtime to allow a team to focus on a strategic or operational issue. Pathfinders generally prefer 24 hours and this includes weekend working

Development interventions – the options available


Before designing the detail of development activities, pathfinders should agree the criteria to be used for evaluation with their delivery partners.

It is difficult to measure a number of development activities in the short term and in detail. The table opposite gives examples of a range of organisational development (“OD”) evaluation criteria that may be applicable to the interventions chosen to support specific development needs.

Development interventions – agreeing the evaluation criteria

Key Performance Indicators

OD Outcomes OD Effectiveness OD Experience

• Success measures for authorisation

• Success measures for delegated responsibility

• Local delivery targets including QIPP

The Roadmap:

• Keycapacityandcapabilityrequirements in place to deliver the elements of the Roadmap

• Useofresourcesspent on OD

• ParticipationinODactivities e.g. % take up, who takes part

• Awarenessofdevelopmentopportunities

• Awarenessoforganisational goals across the pathfinder leadership team and primary care colleagues

• Activesupportofseniorteam in OD activities

• Surveysandfocusgroupsprovide information about the experience of participating in OD activities or the impact of others’ participation

Leadership Development:

• Individualswiththeengagingleadership style and strategic leadership abilities to deliver the transformational change required

• Leaderswithresilience

• Leaderswhocanworkinpartnership

Team Development:

• A leadership team that is able to agree leadership direction and oversee the design of a delivery plan

• A team that is focused on results and committed to delivering a shared outcome

• A team that challenges appropriately both internally and externally


Case studies and Resources

What is the need?

A pathfinder wants to identify its commissioning priorities for 2011/12 and moving forward.

As well as identifying the priorities, the pathfinder needs to understand the capacity and capability required to deliver those intentions and how it can work with the cluster/sub cluster to deliver.

What interventions would suit?

Underlying this need is the question of how the pathfinder makes strategic decisions. It is about the core business processes and how the leadership team works together and with other key stakeholders to deliver its responsibilities.

This intervention will require a good investment of time as the return is high. A ‘lock–in’ over a period of 24 hours would be ideal – perhaps an evening (post surgery) to next day lunchtime is realistic. High calibre facilitation skills would be required to manage the discussion and ensure the group is driven to make hard decisions and generate outputs.

Outcomes

The leadership team has a shared understanding of commissioning priorities now and for the next three years.

There is a clear understanding of the capacity and capability required and key priorities. There is an agreed set of behaviours between the cluster and pathfinder about how to put that in to practice.

Next steps have been identified regarding future development needs and implementation of commissioning plans for 2011/12.

There is recognition that this is the initial point of ongoing and iterative dialogue about delivering health and social care system needs.

What is the need?

The pathfinder has 53 primary care practices. In order to deliver its mission and vision, the pathfinder must ensure that its front line practices are aligned with the strategy and are grouped realistically to provide a manageable framework for corporate and clinical governance.

A range of options for clustering have been identified and these need to be explored and signed up to by the practices.


This is an important early intervention by the pathfinder. Not only does it set a framework for governance issues but also sets the tone of how the pathfinder leadership will engage with practices and make decisions on behalf of the pathfinder. It will also be an early test of how practices are able to engage as a ‘corporate’ entity.

This is an issue that requires dialogue and debate. The following steps to development would help:

• Aleadershipteamsessiontoensure the whole team is clear about mission and vision to ensure clarity from the top of the organisation

• Achallengesessionaboutthemission and vision using expert coaching – e.g. on governance, QIPP, strategy – to test the robustness of the mission

• Alargeengagementeventwithpractices to communicate the vision, suggest models of clustering; and engage in debate to develop an option appraisal

Outcomes

The leadership team has explored and developed their original vision with a deeper understanding of key strategic drivers such as QIPP, governance and organisational design.

The leadership team has a more widely shared view of the vision and has developed an understanding of the value of internal and external challenge.

There is an agreed set of principles about engagement between practices and the pathfinder.

Practices are oriented around the vision and there is a sense of urgency around delivery.

Thinking has shifted to that of a collective across practices.

Case studies – organisational development

VISION AND STRATEGY

VISION AND STRATEGYPLANNING CORPORATE

GOVERNANCECORPORATE

GOVERNANCE

1. Agree commissioning priorities 2. Agree primary care clustering arrangements


Case studies – individual development

What is the need?

The Chairman of the pathfinder has beeninapositionofinfluenceforanumber of years, having been PEC Chair and then PBC lead for the area. He has worked closely with the PCT with which he has an excellent relationship. He is very well regarded by the primary care community.

He now recognises that he needs to reviewhisinfluencingstyleashebegins to work with the local authority. Here he has little authority, and he is bemused by their ways of working and unsure about how to handle the political angle of working together.


The degree of insight this Chairman has is helpful. It is important to help him develop his current strengths and not lose confidence as he widens his fieldofinfluence.

An initial 360° diagnostic tool would help him to understand his strengths and weakness in more depth. This should be supported by feedback in a coaching intervention to plan development actions.

An ongoing relationship with a coach wouldenabletheChairmantoreflecton his developing style and relationship with the local authority. Theuseofareflectivediarywouldsupport this.

The Chairman may also want to consider shadowing a local authority officer for a day to ‘get under the skin’ of the organisation.

Outcomes

The leader has a deeper understanding of external expectations on the organisation.

The leader has greater insight into others’viewsofhisinfluencingandleadership style. Through coaching he hasreflectedontheimpactthishason his effectiveness as a leader.

The leader’s personal development planreflectsongoingsupporttobuildhisinfluencingskillsacrossarangeofpartners. This impacts on the pathfinder by ensuring greater buy–in (e.g. to commissioning intentions), and by building whole system and more effective solutions to health challenges.

What is the need?

Dr P is part of the senior leadership team of the pathfinder. As a senior partner in her practice, she is used to managing budgets and is well versed in balance sheets. However, the scale of the task in delivering QIPP is stretching her financial management skills.

She recognises that in order to appropriately challenge the management support leading the financial input into the pathfinder, she will need to have a better understanding of long-term financial planning.


Dr P needs to feel confident that she is making the right strategic planning decisions by understanding the financial implications of different scenarios. There are a range of interventions she could undertake:

• Using expert sessions and attending workshops will help her understand the context and language of strategic financial management

• Using her own management support for one–to–one financial expert coaching will enable her to contribute to discussions effectively

• Facilitated sessions for the whole leadership team working through different scenarios will enable everyone to understand how decisions will impact on the financial bottom line

Outcomes

At an individual level Dr P has greater confidence in her abilities as a pathfinder leader and is able to effectively challenge colleagues leading to improved solutions. This confidence impacts on other areas of effectiveness. Dr P also feels confident that she can respond to patient queries about the GP role in commissioning with greater clarity, enabling her to maintain the trust of her patients.

At a team level, the leadership team appreciates Dr P’s enhanced inputs, leading to a more balanced debate about a range of critical issues, measured by the positive feedback the team receives from their partners at the Acute Commissioning Vehicle.

At the pathfinder level, the organisation is viewed more credibly, evidenced by the request that they take a lead role on the cluster sector QIPP plan.

VISION AND STRATEGY


FINANCE LEADERSHIP

3. Influencing skills 4. Understanding strategic financial planning


Aims

The aims of the 2 days were to:

• Understandwhatisneededtoachieve delegated responsibilities as a pathfinder

• Agreetangibleobjectivesforthenext 6 months that will enable the pathfinder to operate from 1 April 2011

• Developaresourcedbusinessplanwith practical actions that will:

– Achieve those objectives

– Appropriately and effectively involve all local GPs

– Engage all key stakeholders including other health professionals, the local authority, and cluster

Programme

Day One

4pm to 8pm –

Building the background picture

Building a shared understanding of the context:

• Becominganunstoppableforce!

• Workingpositivelywiththeresidual PCT team/cluster during transition

Day Two

8am to 2pm –

Creating the business plan

• Creatingabusinessplantodeliverthe first six months of the pathfinder

– A very active and practical session that will involve discussion, and agreement on practical tasks and milestones that need to be delivered in the next few months to ‘kick–start’ the pathfinder

– Keeping in mind what is known of the milestones to be met to achieve delegated responsibilities

– The output from the session will be a plan and timeline around the walls, that describes the next few months. This will be quickly typed up and available to circulate to a much wider group of GPs for comment soon after the event

• Discussionontheroles,responsibilities and accountabilities in relation to the delivery of the six month business plan

• NextSteps• Close

Outputs

A six month business plan for the pathfinder.

VISION AND STRATEGY LEADERSHIP


Case studies – example time-out

5. “Making it happen – at a pace”


Texts and Articles

• HeifetzR.,GrashowA.&Linsky M. (2009) The Practice of Adaptive Leadership, Harvard Business Press

• SonnenfeldJ.A.(2002)WhatMakes Great Boards Great, Harvard Business Review Sept 2002 pp. 106–12

• ToftsA.Developingleadershipin the NHS of the 21st century in Mullins L.J. (2007) “Management and Organisational Behaviour – Eighth Edition” Prentice Hall

• TuckmanB.W.andJensen,M.C. Stages of Small Group Development Revised, Group and Organisational Studies, Vol 2. No 3, 1977, pp. 419–27

• ManagementPocketbooks– jargon free, concise guides to a range of leadership skills http://www.pocketbook.co.uk/

Websites

• LeadershipPodcasts–inc.distributed leadership, making change happen and high performance cultures

http://www.cipd.co.uk/podcasts

• ManagingchangeintheNHS– free material hard copy & downloadable

http://www.sdo.nihr.ac.uk/managingchange.html

• NHSConfederation‘FutureofLeadership’ series:

http://www.nhsconfed.org/publications/leadership/pages/leadership.aspx

• NHSEvidence–searchenginefor information on commissioning

http://www.evidence.nhs.uk/search.aspx?t=commissioning

• NHSNationalLeadershipCouncil resources on clinical leadership

http://www.nhsleadership.org

• NHSNetworksiteforcommissioning dialogue and resources

http://www.networks.nhs.uk/nhs–networks/commissioning–zone

• RCGPCommissioningCompetency Framework

http://www.rcgp.org.uk/pdf/Centre_for_Commissioning_Competency_Framework_Dec2010.pdf

• RCGPEffectiveCommissioning

http://www.rcgp.org.uk/centre_for_commissioning/effective_commissioning.aspx

Team Development:

• Teamrolestodeliverresults http://www.belbin.com

Aston

• TeamInventory http://astonod.com

Resources – texts referenced in this guide


The London Pathfinder ToolkitAppendices

Appendix 1:

Example LPI 360° output

Appendix 2:

Development plan templates

Appendix 1: Example LPI 360° outputExample pages from an LPI assessment report are shown below. These show (i) an example set of bar graphs for one of the leadership behaviours (Model the way), and (ii) benchmarking of the individual’s results with the LPI data set.


Appendix 2: Development plan templatesThe London Pathfinder Toolkit includes the following development plan templates for pathfinders to complete: (i) Personal development plan, (ii) Team development plan, (iii) Organisational development plan. All can be downloaded from London’s Online Pathfinder Network.

Development need (as identified through 360° and coaching)


Knowledge • [...] • [...] • [...]

Skills • [...] • [...] • [...]

Behaviours • [...] • [...] • [...]

An example template is included below (personal development plan):


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Documents