Leadership and Management in Health Systems PDF 08/06/2024

08/06/2024 Introduction...

08/06/2024 Introduction Health systems are made up of complex and multiple interacting Leadership and Management in Health components. These components include organizations, people and actions. Systems The components perform several functions as follows: Delivering healthcare services; Maintaining and improving health; Protecting households from the costs of illness; Enabling economic functioning; and, Shaping societal norms and values. The systems components are also sites of competition and contestation between actors with different goals, interests and visions. Rev 12/2018 Leadership and Management 2 Introduction The Concept of Health Systems Health systems cannot be strengthened without good governance, Health systems are complex and are made up of multiple inter- which include good leadership and management. acting components. Therefore, good leadership and management skills are essential at all According to the World Health Organization (WHO), a health levels of health systems. system consists of all ‘organizations, people and actions whose Managers of health systems should therefore embrace leadership and primary intent is to promote, restore or maintain health’. management practices that will lead to improved provision of health Health systems are also usually defined as country-level entities. services and outcomes. This definition renders them large, encompassing both rural and The key leadership and management practices that are critical for the urban areas, public and private systems as well as formal/allopathic health systems include; scanning, focusing, aligning and mobilising, and informal/traditional systems of health provision. inspiring, planning, organising, implementing, and monitoring and evaluation. 3 Rev 12/2018 Leadership and Management 4 1  08/06/2024 Cont… Cont… Health systems perform multiple functions in society. Health systems are open systems that exist in a dynamic relationship They do not merely deliver healthcare services and other interventions with their wider context. aimed at maintaining or improving health. They play a role in protecting households from the financial impacts of Health systems are diffuse systems with poorly defined and often both illness and the costs of healthcare. porous boundaries. Health systems also perform an economic function in society. Therefore, health systems are adaptive and continuously evolving in For example, there is evidence that the health of a population can response to multiple factors. influence economic productivity, while for many health workers and Accordingly, the social, political and economic context of any health businesses, the health system is an economic sector that provides system has to be considered when assessing its structure and employment, wages and business opportunities. performance. Health systems are also social and cultural institutions that play a function in helping establish ‘a wider set of societal norms and values’ Rev 12/2018 Leadership and Management 5 Rev 12/2018 Leadership and Management 6 Cont… Cont… Health systems play an essential social function. Health systems are sites of competition and contestation They shape and reflect relations amongst groups of people in a society. between actors with different needs and wants. For example, national health systems reflect the depth and breadth of the social contract between governments and citizens by determining the scope of health- There is contestation over how health priorities are set, how related rights and entitlements afforded to the citizens or residents. health systems are financed and how resources are allocated within the system. Health systems also shape and reflect the relationship between the different socio-economic segments of society by either reinforcing or There are often ideologically and politically contrasting visions mitigating the relationship between social inequalities and health of what role a health system should play in society and what role the state and the market should play within health inequalities. systems The degree to which healthcare is affordable, accessible and responsive is also a critical determinant of social mobility. Rev 12/2018 Leadership and Management 7 Rev 12/2018 Leadership and Management 8 2  08/06/2024 The Concept of Good Governance Cont… Good governance connotes certain value-assumptions, whereas governance as a Governance refers to: process denotes a value –free dispensation. (i) The manner in which power is exercised in the management of a country’s Good governance is associated with efficient and effective administration in a economic and social resources for development – World Bank. democratic framework – linked to society and human rights. The exercise of political, economic and administrative authority in the It is equivalent to purposive and development oriented administration which is management of a country's affairs at all levels, comprising the complex committed to improvement in quality of life of the people. mechanisms, processes, relationships and institutions through which citizens and It implies high level of organizational effectiveness. groups articulate their interests, exercise their rights and obligations and mediate It also relates to the capacity of the centre of power of political and administrative their differences. system to cope up with the emerging challenges of the society. (ii) the traditions and institutions by which authority in a country is exercised for It refers to adoption of new values of governance to establish greater efficiency, the common good, including the processes by which those in authority are legitimacy and credibility of the system. selected, monitored and replaced; the capacity of the government to effectively manage its resources and implement sound policies; and the respect of citizens Good governance is, thus, a function of installation of positive virtues of and the state for the institutions that govern economic and social interactions administration and elimination of vices of dysfunctionalities and malfuntionalities. among them. In short, it must have the attributes of an effective, credible and legitimate administrative system- citizen-friendly, value-caring and people-sharing. Rev 12/2018 Leadership and Management 9 Rev 12/2018 Leadership and Management 10 Health Systems Governance Cont… Health systems governance refers to the processes, structures and Effective health systems governance is essential for ensuring that institutions that are in place to oversee and manage a country's healthcare services are accessible, equitable, efficient, affordable and of healthcare system. high quality for all. It manages the relationships between different actors and stakeholders This requires efficient and equitable allocation of healthcare resources, involved in healthcare, including government agencies, healthcare the presence of policies and regulations guiding healthcare delivery, and providers, patients and their families, people and communities, civil mechanisms for monitoring, evaluating and reviewing the healthcare system’s performance. society organizations and private sector entities. Moreover, health systems governance plays a crucial role in promoting Health systems governance means ensuring strategic policy frameworks equity and social justice in healthcare. exist and are combined with effective oversight, coalition-building, It strives to ensure that the healthcare system is responsive to the needs provision of appropriate regulations and incentives, attention to system of all members of society, regardless of their socioeconomic status, design, and accountability. ethnicity, culture, gender or other factors. Rev 12/2018 Leadership and Management 11 Rev 12/2018 Leadership and Management 12 3  08/06/2024 The Legal Foundation for Good Health Systems Cont… Governance (Leadership and Management) The legal foundation of good governance, leadership, and management in 1. Principles of governance: The Constitution outlines the principles of Kenya is primarily based on the Constitution of Kenya, which was governance, including the rule of law, participation of the people, transparency, accountability, and sustainable development. promulgated in 2010. 2. Leadership and management: The Constitution defines the roles and The Constitution 2010 is the overarching law, which provides the responsibilities of various state organs, such as the Executive, Legislature, overarching legal framework for governance and outlines the principles and Judiciary, as well as the functions of county governments. and values that should guide the conduct of public and private affairs. It also sets out the qualifications, selection, and accountability mechanisms for public officers including health systems leaders and managers. The Constitution binds both public/state institutions and officers as well 3. Public finance management: The Constitution provides guidance on public private institutions and individuals. finance management, including the budgeting process, revenue collection, Some key aspects of the legal foundation for good governance, and expenditure control. This also relates to health systems management. leadership, and management in Kenya include: Rev 12/2018 Leadership and Management 13 Rev 12/2018 Leadership and Management 14 Cont… National Values and Principles of Governance Established under Article 10 of the Constitution 2010 4. Oversight and accountability: The Constitution establishes various The national values and principles of governance in this Article bind all independent commissions and offices, such as the following: State organs, State officers, public officers and all persons whenever any of Ethics and Anti-Corruption Commission. them: The Auditor-General. (a) applies or interprets this Constitution; (b) enacts, applies or interprets any law; or the Commission on Administrative Justice. (c) makes or implements public policy decisions. These bodies provide oversight and ensure accountability in the public sector. The national values and principles of governance include: (a) patriotism, national unity, sharing and devolution of power, the rule of law, 5. Devolution: The Constitution introduces a devolved system of democracy and participation of the people; government, with the transfer of power and resources to county (b) human dignity, equity, social justice, inclusiveness, equality, human rights, non- governments, which are expected to promote good governance and discrimination and protection of the marginalised; responsive service delivery at the local level. (c) good governance, integrity, transparency and accountability; and (d) sustainable development. Rev 12/2018 Leadership and Management 15 Rev 12/2018 Leadership and Management 16 4  08/06/2024 Leadership and Integrity – Chapter Six of the Constitution 2010 Chapter 13 of the Constitution - Part I-Values and The Constitution of Kenya recognizes that constitutionalism and rule of law Principles of Public Service depend on integrity in leadership and management. The Constitution has guiding principles of leadership and integrity, which Article 232. (1) The values and principles of public service include: include: selfless service and honesty, accountability to the public for decisions (a) high standards of professional ethics; and actions, and discipline and commitment in service to the people (Art 73(2)). The guiding principles of leadership and integrity include: (b) efficient, effective and economic use of resources;  (a) selection on the basis of personal integrity, competence and suitability…; (c) responsive, prompt, effective, impartial and equitable provision of services;  (b) objectivity and impartiality in decision making, and in ensuring that decisions are not influenced by nepotism, favouritism, other improper motives or corrupt practices; (d) involvement of the people in the process of policy making;  (c) selfless service based solely on the public interest, demonstrated by: (e) accountability for administrative acts;  (i) honesty in the execution of public duties; and (f) transparency and provision to the public of timely, accurate information;…  (ii) the declaration of any personal interest that may conflict with public duties.  (d) accountability to the public for decisions and actions; (2) The values and principles of public service apply to public service in-all and State organs in both levels of government; and all state corporations. (e) discipline and commitment in service to the people. Rev 12/2018 Leadership and Management 17 Rev 12/2018 Leadership and Management 18 A Leader... A Leader Very simply put, a leader is interpreted as someone who sets direction in an effort to influence people to follow that direction. The people can be oneself, another individual, a group, an organization or a community. 19 20 5  08/06/2024 Management Is Leading Different from Managing? Management is the process of controlling things and people. Management Leadership Managing can be defined as Leading is mobilising others to planning and using resources envision and realise a better efficiently to produce intended future. results. While managing is focused on Managing is focused on making the present, leading is focused sure present operations are going the future. well. 21 22 What Leadership and Management Share Summary Professionalism Leaders and managers have different goals. Knowledge Good leaders do not always make good managers and vise versa. Interpersonal skills Leaders and managers need the buy in from those they lead or manage. Motivation is one tool to encourage buy-in. 23 24 6  08/06/2024 Context of Leadership and Management in Health Cont... Systems The key general objectives of a health care system needs are to: Good health management and leadership results in measurable improvements in health services and outcomes. Heath managers’ Improve the health status of the population (according to certain leadership and management skills therefore not only matter to their teams criteria and targets); but also to those who benefit from their team’s improved performance. Deliver services in the most efficient way possible in order to Can be improved by embracing tested practices of challenging, providing accomplish the first goal. feedback and supporting your team. By so doing, you transform yourself The task involved in producing health services require the coordination into a manager who leads. However, learning to lead and manage takes of many specialised disciplines and support services that must work time and practice. Leading and managing comprise skills, knowledge, and together seamlessly. attitudes that you learn through continued practice. Management and leadership are therefore needed to make sure that It follows from the above that health gains can only be sustained by making tasks are carried out in the best way possible and that appropriate sure that leadership and management practices are used in all health resources are adequate and well managed. services and supported by organisational systems and processes for Leadership and management is one of the health system building blocks managing governance, planning, human resources, finances, medicines and as discussed in the last class. other health products, and information. 25 26 Principles of Leadership The Process of Great Leadership Know yourself and seek self-improvement Be technically proficient Seek responsibility Take responsibility for yourself Make sound and timely decisions Inspire a Enable Set the example Challenge Encourage shared others to Know your people and look out for their well-being the Process the heart vision act Keep your workers informed Develop a sense of responsibility in your workers Ensure that tasks are understood, supervised, and accomplished 27 28 7  08/06/2024 Leadership Competencies Management and Leadership Practices The objective of good leading and managing practices is to enhance organisational:  Effectiveness- the right services are offered Efficiency- services delivered in the right way Sustainability. To be effective, a health manager should:  Plan how to achieve results by assigning resources, accountabilities, and timelines;  Organise people, structures, systems, and processes to carry out the plan;  Implement activities efficiently, effectively, and responsively to achieve defined results; 29 30 Management and Leadership Practices Management and Leadership Practices Good leadership and management practices are those which focus on Monitor and evaluate achievements and results against plans, and achieving results that fulfil client needs and preferences, as well as continuously update information and use feedback to adjust plans, respond to key stakeholder interests. structures, systems, and processes for future results. To be an effective leader or manager, one should; Scan for up-to-date knowledge (to be aware how your behaviour and Implement activities efficiently, effectively, and responsively to achieve values affect others), your work group, your organisation, and your defined results; environment; Focus staff ’s work on achieving organisational mission, strategy, and priorities; Align and mobilise stakeholders’ and staff ’s time and energies as well as the material And financial resources to support organisational goals and priorities; Inspire your staff to be committed and to continuously learn how to adapt and do things better. 31 32 8  08/06/2024 Leading and Managing Framework Leading and Managing Framework The Leading and Managing Framework presents activities and organisational outcomes associated with each leading and managing practice. By applying the eight practices consistently, health managers, team leaders, supervisors, teams and organisations can systematically make improvements that will strengthen their services and improve health outcomes. In other words, applying the eight practices consistently should deliver results for leaders and managers as shown in the following results model. 33 34 Leading and Managing for Results Model Integrating Leading and Managing practices Leading and managing occurs simultaneously. They are not distinct, sequential processes that are completed separately. The leading practices are not independent of the managing practices. They complement and support each other. Effective managers move fluidly between leading and managing to support their teams to face challenges and achieve results. Source: Management Sciences for Health (2005). 35 36 9  08/06/2024 Integrating Leading and Managing practices Integrating Leading and Managing practices Management Produces Leadership Produces Facing challenges involves Planning and budgeting Establishing direction scanning, focusing and planning. Establishing agendas Creating a vision The process of scanning the Setting timetables Clarifying the big picture environment to identify challenges Allocating resources Setting strategies is followed by a deliberate effort to Organizing and staffing focus on a few priority challenges Aligning people and making a plan to address Provide structure Making job placements Communicating goals them. Establishing rules and procedures Seeking commitment Planning is followed by building Controlling and problem solving Building teams and coalitions stakeholder support, mobilising Developing incentives Motivating and inspiring resources and implementing the Generating creative solutions Inspiring and energize plan. Taking corrective action Empowering subordinates Source: Management Sciences for Source: Kotter (1990). Health (2005). Satisfying unmet needs 37 38 Team Management in Health Care Settings Exercis What would you do? Provision of health care and health care management and leadership takes place e in a group or team setting. A team is a group of people who work together to achieve a common goal. The literature on teams underscores that a team’s structure differs depending on its Cost are increasing while profits are declining. purpose, task, setting, the mix of professions on the team, and the formal As a manager? relationships between health professionals in the team. A team may be defined as a collection of individuals who are interdependent in As a leader? their tasks, who share responsibility for outcomes, see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems and who manage their relationships across organisational borders (Hackman, 1978). The best and most cost-effective outcomes for patients and clients are achieved when professionals work together, learn together, engage in clinical audit of outcomes together, and generate innovation to ensure progress in practice and service. 39 40 10  08/06/2024 Types of Medical Teams Core Teams The teams in health care include labour and delivery units, ICUs, medical wards, primary care teams in the community, teams assembled for a specific task such as an emergency response team or multi-professional Core teams consist of team leaders and members who are involved in the teams such as multidisciplinary cancer care teams that come together to direct care of the patient. plan and coordinate a patient’s care. They include direct care providers (from the home base of operation for Teams can include a single discipline or involve the input from multiple each unit) and continuity providers (those who manage the patient from practitioner types including doctors, nurses, pharmacists, physiotherapists, social workers, psychologists and potentially administrative staff. assessment to disposition, for example, case managers). The role played by each of these practitioners varies between teams. Roles The core team, such as a unit-based team (physician, nurses, of individuals in the team are often flexible and opportunistic such as the physiotherapist, and pharmacist) is generally based where the patient leadership changing depending on the required expertise or the nurse receives care. taking on the patient education role given, they have regular contact with patients. 41 42 Coordinating Teams Contingency Teams A coordinating team is the group responsible for: Contingency teams are: Day-to-day operational management; Formed for emergent or specific events; Coordination functions; Time-limited events (e.g. cardiac arrest teams, disaster response Resource management for core teams. teams, rapid response teams); Composed of team members drawn from a variety of core teams. 43 44 11  08/06/2024 Ancillary Services Support Services Ancillary services consist of individuals such as catering, cleaners and other support staff who: Provide direct, task-specific, time-limited care to patients; Support services consist of individuals who: Support services that facilitate care of patients; 1. Provide indirect, task-specific services in a health-care facility; Are often not located where patients receive routine care. 2. Are service-focused, integral members of the team, helping to Ancillary services are primarily a service delivery team whose mission is to facilitate the optimal health care experience for patients and their support the core team. This does not mean that they should not share the same families. goals. The successful outcome of a patient undergoing surgery requires accurate Support services consist primarily of a service focused team whose information on catering and instructions in relation to “nil by mouth” orders so mission is to create efficient, safe, comfortable and clean health- that a patient does not inadvertently receive a meal that may place them at risk care environments, which impact the patient care team, market of choking. In general, an ancillary services team functions independently. However, there perception, operational efficiency and patient safety. may be times when they should be considered as part of the core team. 45 46 Administration The challenge Model Administration includes the executive leadership of a unit or facility and has 24-hour accountability for the overall function and management of the organisation. Administration shapes the climate and culture for a teamwork system to flourish by: a. Establishing and communicating vision; b. Developing and enforcing policies; c. Setting expectations for staff; d. Providing necessary resources for successful implementation; e. Holding teams accountable for team performance; f. Defining the culture of the organisation. 47 48 12  08/06/2024 What is a Team? A Team refers to two or more people who share a common meaning and evaluation of themselves and come together to achieve common goals. Every organization is a Team and every department in an organization is also a Team. Team dynamics is the lifeblood of a team. Team dynamics is built on basic 3Cs – communication, cooperation/coordination, collaboration. Sometimes we talk of 8Cs or 12Cs. Team dynamics affects team’s innovation and productivity, satisfaction, performance and overall success towards a shared common goal. Behind every successful team, there are team dynamics – the key differences that need to be harnessed to either make or break the team. Team dynamics help members to build trust, inculcate a sense of unity, work together cohesively, and move towards a common goal. Rev 12/2018 Leadership and Management 49 Rev 12/2018 Leadership and Management 50 Characteristics of a Team Characteristics of a Team Consists of two or more persons Norms and rules delineate the parameters that govern behaviour, It is a formal social structure – has defined norms and rules conduct and operations. Common fate/stake – stand together/die together? Fate correlates with stake – stand together/die or perish together. This is where the team finds the joinder – the gluing mechanism. Common Identity and goals Interdependence and interrelations: The strength of the team is each Face to face interaction individual member while the strength of each member is the team. The Interdependence members should serve the team and the team should serve the Self-definition as group members members best and optimally. Recognition by others Self definition also equals self determination. Rev 12/2018 Leadership and Management 51 Rev 12/2018 Leadership and Management 52 13  08/06/2024 Characteristics of an Effective Team Components of Successful Teamwork Common purpose; Team members generate a common and clearly defined Open communication. purpose that includes collective interests and demonstrates shared ownership. Measurable goals; Teams set goals that are measurable and focused on the Non-punitive environment. team’s task. Clear direction. Effective leadership that set and maintain structures, manage leadership conflict, Clear and known roles and tasks for team members. listen to members and trust and support members. Respectful atmosphere. Share ideas and information quickly and regularly, keep communication written Shared responsibility for team success. records as well as allow time for team reflection. Some of the most in-depth analysis of inter-professional team communication has occurred in high stakes Appropriate balance of member participation for the task at hand. teams such as are found in surgery. Acknowledgment and processing of conflict. Good cohesion; unique and identifiable team spirit and commitment and have Clear specifications regarding authority and accountability. greater longevity as teams' members want to continue working together. Clear and known decision making procedures. Mutual respect Effective teams have members who respect the talents and Regular and routine communication and information sharing. beliefs of each person in addition to their professional contributions. In addition, Enabling environment, including access to needed resources. effective teams accept and encourage a diversity of opinion among members. 53 Mechanism to evaluate outcomes and adjust accordingly. 54 Common Barriers to Inter-Professional Collaboration Models for Understanding Team Dynamics Personal values and expectations Personality differences Disruptive behaviour An important aspect of effective teamwork entails understanding Culture and ethnicity team dynamics in terms of both team situation and individual Generational differences Historical inter-professional and intra-professional rivalries temperament. Differences in language and jargon It also entails understanding the various stages of team development. Differences in schedules and professional routines Varying levels of preparation, qualifications, and status There are a variety models often applied in workplaces that can help Differences in requirements, regulations, and norms of professional education in understanding the various stages of team development and help a Fears of diluted professional identity team perform optimally and manage crises effectively. Differences in accountability, remuneration, and rewards Concerns regarding clinical responsibility Complexity of care Emphasis on rapid decision making 55 14  08/06/2024 The Tuckman Model Tuckman’s Stages of Group Development was proposed by psychologist Bruce Tuckman in 1965. It is one of the most famous theories of team development. It describes four stages that teams may progress through: forming, storming, norming, and performing (a 5th stage was added later: adjourning). The stages move from organizing to producing. Although the stages appear linear, in fact teams may move backwards to previous stages, depending on events that may influence the team and the communications strategies that they use. Some teams can also stall in a stage and never fully realize their potential. Note that at each stage, effective communication is a critical component of successfully moving to the next stage Rev 12/2018 Leadership and Management 58 Stage 2: Storming Stages of Team Development Characterised by competition and conflict in the personal relations within the group. Attempts to organise for the task, conflict inevitably results in Stage 1: Forming their personal relations. Personal relations are characterised by dependence. Group members Individuals have to bend and mold their feelings, ideas, attitudes, and rely on safe, patterned behaviour and look to the group leader for beliefs to suit the group organisation. Because of “fear of exposure” or “fear of failure”, there is an increased desire for structural clarification guidance and direction. and commitment. Although conflicts may or may not surface as group Group members have a desire for acceptance by the group and a need issues, they do exist. to know that the group is safe. Questions will arise about who is going to be responsible for what, what the rules are, what the reward system is, and what the criteria for They set about gathering impressions and data about the similarities evaluation are. and differences among them and forming preferences for future These reflect conflicts over leadership, structure, power, and authority. subgrouping. There may be wide swings in members’ behaviour based on emerging Rules of behaviour seem to be to keep things simple and to avoid issues of competition and hostilities. controversy. Serious topics and feelings are avoided. Because of the discomfort generated during this stage, some members 59 may remain completely silent while others attempt to dominate. 60 15  08/06/2024 Stage 3: Norming Stage 4: Performing In this stage, people can work independently, in subgroups, or as a total unit Interpersonal relations are characterised by cohesion. Group members with equal facility. Their roles and authorities dynamically adjust to the are engaged in active acknowledgment of all members’ contributions, changing needs of the group and individuals. group building and maintenance, and solving of group issues. Marked by interdependence in personal relations and problem solving in the Members are willing to change their pre-conceived ideas or opinions realm of task functions. based on facts presented by other members, and they actively ask At this stage, the group should be most productive. Individual members become questions of to another. self-assuring, and the need for group approval is past. Members are both highly Leadership is shared, and cliques' dissolve. When members begin to know task-oriented and people-oriented. and identify with one another, the level of trust in their personal relations There is unity: group identity is complete, group morale is high, and group contributes to the development of group cohesion. loyalty is intense. The task function becomes genuine problem solving, leading It is during this stage of development (assuming the group gets this far) towards optimal solutions and group development. There is support for that people begin to experience a sense of group belonging and a feeling experimentation in problem-solving and emphasis on achievement. The overall of relief as a result of resolving interpersonal conflicts. goal is productivity through problem-solving and work. 61 62 Stage 5: Adjourning It involves break-up of the group, hopefully when the task is completed successfully, and its purpose fulfilled. Everyone can move on to new things, feeling good about what has been achieved. From an organisational perspective, recognition of, and sensitivity to people's vulnerabilities is essential, especially if members have closely bonded and feel a sense of insecurity or threat from this change. 63 16  08/06/2024 Barriers to Effective Teamwork Exercis Barriers to Effective Teamwork? e Changing roles There are currently considerable change and overlap in the roles played by different health- care professionals. Examples include radiographers reading plain film X-rays, nurses performing colonoscopies and nurse practitioners having prescribing rights. These changing roles can present challenges to teams in terms of role allocation and acknowledgement. Leadership and Management Rev 1/2018 65 66 Changing settings Medical hierarchies The nature of health care is changing including increased delivery Medicine is strongly hierarchical in nature, and this is of care for chronic conditions into community care and many counterproductive in terms of establishing and effectively running surgical procedures to day-care centres. teams where all members’ views are accepted, and the team leader These changes require the development of new teams and the is not always a doctor. modification of existing ones. While there has been a growing acknowledgement that teamwork is important in health care, this has not necessarily been translated into change practices, especially in environments where cultural norms of communication may mitigate against teamwork. 67 68 17  08/06/2024 Individualistic nature of medicine Instability of teams The practice of medicine is based on the autonomous one-on-one As already indicated, health-care teams are often transitory in relation between the doctor and patient. nature, coming together for a specific task or event (such as cardiac While this relationship remains a core value, it is challenged by arrest teams). many concepts of teamwork and shared care. The transitory nature of these teams' places great emphasis on the This can be at many levels including doctors being unwilling to quality of training for team members, which raises particular share the care of their patients through to medico-legal challenges in medicine where education and training is often implications of team-based care. relegated at the expense of service delivery. 69 70 Types and Sources of Conflict Managing Conflict within Health Teams Conflict can be classified as constructive or destructive. Constructive We experience conflict in our everyday lives and probably have many feelings about it. Conflict situations are an important aspect of the workplace. (functional) conflict helps a group achieve its objectives. Destructive Webster’s Ninth New Collegiate Dictionary defines conflict as a fight, battle, (dysfunctional) conflict hinders achievement of objectives. war meaning: A manager's job is to eliminate destructive conflict or change it into i. Competitive or opposing action of incompatibles: antagonistic state or constructive conflict. action (as of divergent ideas, interests, or persons). Conflict may also be classified in terms of the people involved: ii. Mental struggle resulting from incompatible or opposing needs, drives, wishes, or external or internal demands. Individual conflict when faced with contradictory priorities; The opposition of persons or forces that gives rise to the dramatic action in Interpersonal conflict between two people; a drama or fiction. Conflict between an individual and a group when the individual breaks This definition expresses what people usually mean by ‘conflict’. As implied the group's norms; in the second part of the dictionary definition, conflict is not bad. Conflict Conflict between groups or departments; involves competing or opposing forces. The conflict may be about ideas, interests, or just differences between people. Conflict is therefore an Conflict between stakeholders in a health system. outgrowth of diversity (Dudley, 1994). 71 72 18  08/06/2024 Causes of Conflict in Organisations Conflict Management Models/Techniques Personal differences; Often arise from different needs, beliefs, Various models and techniques exist and are used as follows. values, perceptions and expectations 1. The DISC Model. Information; Arises from the use of different sources of 2. The GRIP Model. information or different interpretations of the same information. 3. The Thomas Kilman Model. Different objectives; Individuals and groups can have different or 4. The Lencioni Model. incomparable objectives. Environmental factors; Competition for organisational resources. 73 Rev 12/2018 Leadership and Management 74 DISC Model Disc Model Disc Model DISC theory was developed in 1928 by Dr. William Moulton Marston (who also, as it happens, created the Wonder Woman comic series!). It has evolved into a useful model for conflict management. It predicts behaviours based on four key personality traits he originally described as Dominance, Inducement, Submission, and Compliance. The names of these four traits have been variously revised by others over the decades, so you might find different terms used in different contexts. The four general traits are now often described as (1) Dominance, (2) Influence/Inspiring (3) Steadiness/Supportive, and (4) Compliance/Conscientiousness. Having some insight into your teammates’ personality traits can help when trying to resolve conflicts. General characteristics of each trait are as follows. Rev 12/2018 Leadership and Management 76 19  08/06/2024 Dominance Inspiring/Influential – Characteristics: enthusiastic, persuasive, optimistic, trusting, – Characteristics: direct, decisive, ego-driven, problem-solver, impulsive, charismatic, and emotional. and risk-taker; likes new challenges and freedom from routine; driven to overcome obstacles. – Strengths: creative problem solver; great cheer-leader, negotiator, and peace-maker; a real “people person”. – Strengths: great organizer and time manager; challenges the status quo; innovative. – Weaknesses: more concerned with popularity than tangible results; lacks attention to detail. – Weaknesses: can be argumentative, disrespectful of authority, and overly ambitious (taking on too much); can be blunt, stubborn, and aggressive. Cautious/Conscientious/Compliant Steady/Supportive – Characteristics: reliable, predictable, friendly, good – Characteristics: has high standards; values precision and listener, team player, empathetic, easy-going, and altruistic. accuracy; analytical and systematic; even-tempered, realistic, and logical; methodical; respect for authority. – Strengths: dependable, loyal; respects authority; has patience and empathy; good at conflict resolution; willing – Strengths: great information gatherer/researcher; able to define situations precisely and accurately; offers realistic to compromise. perspective. – Weaknesses: resistant to change; sensitive to criticism; – Weaknesses: can get bogged down in details; needs clear difficulty prioritizing boundaries, procedures, and methods; difficulty accepting criticism; may avoid conflict or just “give in.” May be overly timid. 20  08/06/2024 GRIP Model GRIP Model Richard Beckhard’s GRIP model was originally developed in 1972 and has been widely adapted in sports contexts. The GRIP model outlines four interrelated components of highly effective teamwork Goals: everyone must fully understand and be committed to the goals of the team, and of the organization. Everyone’s goals must be aligned in order to establish trust, make progress, and achieve desired outcome. Roles: all team members must know what part they play, what is expected, and how they are held accountable and responsible. Interpersonal: quality communication and collaboration require and foster trust among team members; sensitivity and flexibility needed to deal with conflict and make progress. Processes: defined system for how decisions are made, how the team solves problems and addresses conflict; defines work flow and procedures to be followed in completing the project. Rev 12/2018 Leadership and Management 82 Thomas-Kilmann Conflict Mode Model Thomas Kilman Model 1. Competing: highly assertive, but uncooperative behaviour, characterized by the urge to “win at all costs,” dominate, and engage in power struggles. This can result in animosity, but can also spur teammates to compete constructively, which can lead to interesting Thomas and Kilmann’s model for handling team conflict outlines innovations if well managed. 2. Accommodating: highly cooperative, but unassertive behaviour. This may seem like a five main approaches to managing team conflict. good way to avoid conflict, but it can also lead to self-silencing of good ideas in order to These are Competing, Accommodating, Compromising, Avoiding, appease others, which may lead to feelings of resentment. 3. Compromising: this approach is the most moderate in both scales, and while it might and Collaborating, placed in a matrix of two scales as follows: seem constructive, it can lead to dissatisfaction and mediocre progress or results. – 1. Assertiveness—the degree to which one tries to meet one’s Sometimes compromise is necessary, but often, the best solution comes from a single inspirational source. own needs; and, 4. Avoiding: being unassertive and uncooperative is generally the least effective way to – 2. Cooperativeness—degree to which one tries to satisfy the deal conflict, as this simply avoids the problem and neglects the need for a solution. However, when a feasible solution to a problem seems impossible, sometimes ignoring needs of other team members. it and focusing on what is good can be the best way to just get through it. 5. Collaborating: being highly assertive and cooperative is the best way to find solutions that benefit the whole team and build respect. Rev 12/2018 Leadership and Management 83 21  08/06/2024 Lencioni Model Lencioni Model In his 2005 book, The Five Dysfunctions of a Team, Lencioni outlines five common problems teams experience that impact their effectiveness. Lencioni advises tackling each dysfunction, displayed in the pyramid from the bottom up. Establishing trust is a crucial first step to being able to manage conflict, achieve commitment, create accountability and focus on results. 1. Lack of trust: if team members do not trust each other, they are unlikely to take risks or ask for help. A lack of trust means a low level of comfort that makes it difficult to communicate and perform effectively as a team 2. Fear of conflict: avoiding conflict can lead to an artificial “peace” at the expense of progress and innovation. Conflict is a normal part of team work and can be very productive if managed effectively. 3. Lack of commitment: team members do not commit to doing the work, do not follow through on decisions or tasks, do not meet deadlines, and let their teammates down, ultimately affecting the success of the whole project. 4. Avoidance of accountability. 5. Inattention to results: when team members focus on their own personal goals instead of project goals, they lose sight of the expected results that actually measure the success of the project. Not focusing on the results Rev 12/2018 during the process means that no one is planning Leadership and Management 85 how to improve those results. Conflict Management Techniques – The Commonly Possible advantages of forcing are: Used Thomas Kilman Model May provide a quick resolution to a conflict; 1. Forcing Increases self-esteem and draws respect when firm resistance or Also known as competing. An individual firmly pursues his or her own concerns actions were a response to an aggression or hostility. despite the resistance of the other person or party. A user of the forcing conflict style attempts to resolve the conflict by getting his or her way. Some caveats of forcing include: It is an assertive, uncooperative, autocratic style that attempts to satisfy one’s May negatively affect your relationship with the opponent in the needs at the expense of those of others. It creates a win-lose situation. long-run; Examples of when forcing may be appropriate; May cause the opponent to react in the same way, even if the In certain situations when all other, less forceful methods, do not work or opponent did not intend to be forceful initially; are ineffective; Cannot take advantage of the strong sides of the other side’s When you need to stand up for your own rights, resist aggression and position; pressure; Taking this approach may require a lot of energy and be exhausting When a quick resolution is required and using force is justified (e.g. in a life- to some individuals. threatening situation, to stop an aggression); As a last resort to resolve a long-lasting conflict. 87 88 22  08/06/2024 2. Win-win (Collaborating) Possible advantages of collaborating are: Also known as problem-confronting or problem-solving. Leads to solving the actual problem; Collaboration involves an attempt to work with the other person to find a win-win solution to the problem in hand. Leads to a win-win outcome; Sees conflict resolution as an opportunity to come to a mutually Reinforces mutual trust and respect; beneficial result. Builds a foundation for effective collaboration in the future; It includes identifying underlying concerns of the opponents and finding an alternative which meets each party's concerns. Shared responsibility of the outcome; Examples of when collaborating may be appropriate are: You earn the reputation of a good negotiator; When consensus and commitment of other parties is important; For parties involved, the outcome of the conflict resolution is When it is required to address the interests of multiple stakeholders; less stressful. When a long-term relationship is important; However, the process of finding and establishing a win-win When you need to work through hard feelings, animosity, etc.; solution may be very involved. When you do not want to take full responsibility. 89 90 Some caveats of collaborating include: 3. Compromising A commitment from all parties to look for a mutually acceptable solution; Compromising looks for an expedient and mutually acceptable solution which partially satisfies both parties. This style is an attempt May require more effort and more time than some other methods. to resolve conflict through give and take and by making concessions. A win-win solution may not be evident; It involves both assertiveness and cooperation and attempts to For the same reason, collaborating may not be practical when meet a person's needs for harmonious relationships. A win-lose or timing is crucial, and a quick solution or fast response is required; lose-lose situation may result. Once one or more parties lose their trust in an opponent, the relationship falls back to other methods of conflict resolution. Therefore, all involved parties must continue collaborative efforts to maintain a collaborative relationship. 91 92 23  08/06/2024 Examples of when compromise may be appropriate: When the goals are moderately important and not worth the use of more assertive or more involving approaches, such as forcing or Some caveats of using compromise include: collaborating; May result in a situation when both parties are not satisfied with To reach temporary settlement on complex issues; the outcome (a lose- lose situation); To reach expedient solutions on important issues; Does not contribute to building trust in the long-run; As a first step when the involved parties do not know each other well or have not yet developed a high level of mutual trust; May require close monitoring and control to ensure the When collaboration or forcing do not work. Possible advantages of agreements are met. compromise are: Faster issue resolution. Compromising may be more practical when time is a factor; Can provide a temporary solution while still looking for a win-win solution; Lowers the levels of tension and stress resulting from the conflict. 93 94 Examples of when withdrawing may be appropriate include: 4. Withdrawing When the issue is trivial and not worth the effort; This is also known as avoiding. This is when a person does not pursue When more important issues are pressing, and you do not have time her/his own concerns or those of the opponent. He/she does not to deal with it; address the conflict, sidesteps, postpones or simply withdraws. In situations where postponing the response is beneficial to you; When it is not the right time or place to confront the issue; Someone using this style attempts to ignore conflict rather than When you need time to think and collect information before you act resolve it. It is unassertive and uncooperative and represents an e.g. if you are unprepared or taken by surprise; attempt to satisfy needs by avoiding or postponing confrontation. A When you see no chance of getting your concerns met or you would lose-lose situation is created. have to put forth unreasonable efforts; When you would have to deal with hostility; When you are unable to handle the conflict e.g. if you are too emotionally involved or others can handle it better. 95 96 24  08/06/2024 Possible advantages of withdrawing are: Some caveats of withdrawing include: When the opponent is forcing/attempts aggression, you may May lead to weakening or losing your position; not acting may choose to withdraw and postpone your response until you are in a be interpreted as an agreement. more favourable circumstance for you to push back; Using withdrawing strategies without negatively affecting your Withdrawing is a low stress approach when the conflict is short; own position requires certain skill and experience; Gives the ability/time to focus on more important or more urgent When multiple parties are involved, withdrawing may negatively issues instead; affect your relationship with a party that expects your action. Gives you time to better prepare and collect information before you act. 97 98 5. Smoothing Possible advantages of smoothing are: This is also known as accommodating. Smoothing is accommodating the In some cases, smoothing will help to protect more important interests concerns of other people first of all, rather than one's own concerns. while giving up on some less important ones; Someone using this style resolves the conflict by giving in to the other Gives an opportunity to reassess the situation from a different angle. party. It is unassertive and cooperative and attempts to satisfy the other party while neglecting his or her own needs. Some caveats of smoothing: A win-lose situation is created with the other party winning. There is a risk to be abused, i.e. the opponent may constantly try to take Examples of when smoothing may be appropriate: advantage of your tendency toward smoothing/accommodating. When it is important to provide a temporary relief from the conflict or Therefore, it is important to keep the right balance, and this requires buy time until you are in a better position to respond/push back; some skill; When the issue is not as important to you as it is to the other person; May negatively affect your confidence in your ability to respond to an When you accept that you are wrong; aggressive opponent; When you have no choice or when continued competition would be It makes it more difficult to transition to a win-win solution in the future; detrimental. Some of your supporters may not like your smoothing response. 99 100 25  08/06/2024 References References The Constitution of Kenya 2010: https://www.kenyalaw.org/kl/index.php?id=398 B. Tuckman, "Developmental sequence in small groups," Psychological Bulletin, vol. 63, no. 6, pp. 384-399. Available: http://dx.doi.org/10.1037/h0022100 The Public Finance Management Act 2012: https://www.treasury.go.ke/acts/public- finance-management-act.html S. McCahan, P. Anderson, M. Kortschot, P. E. Weiss, and K. A. Woodhouse, “Introduction to teamwork,” in Designing Engineers: An Introductory Text, Hoboken, NJ: Wiley, 2015, pp. 219- The Leadership and Integrity Act 2012: https://www.kenyalaw.org/kl/index.php?id=3835 246. The Ethics and Anti-Corruption Commission Act eCampus Ontario. “Tuckman’s Linear Model of group development”, in Communication for 2011: https://www.eacc.go.ke/WHATWEDO/EACC-Act.aspx Business Professionals - Canadian Edition [Online]. eCampus Ontario, 2018. The County Governments Act 2012: https://www.kenyalaw.org Available: https://ecampusontario.pressbooks.pub/commbusprofcdn/. CC-BY-SA. W. M. Marsten, Emotions of Normal People. Keegan Paul Trench Trubner and Co. 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